Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Locust Grove Village during CMS and state inspections, most recent first.
Lack of Required RN Coverage: The facility failed to maintain RN coverage for 8 consecutive hours a day, 7 days a week. Nursing schedules for multiple months showed no RN coverage on numerous dates, and the facility could not provide verifiable, auditable evidence of RN coverage. An admin nurse stated there was no RN in the building on those dates, though she was on call, and an admin staff member said the facility expected an RN in the building for 8 hours a day and had discussed a nursing waiver.
The facility failed to provide the services of a full-time CDM for the 36 residents who received meals from the kitchen. Dietary staff stated there was no CDM in place, one staff member was serving as kitchen supervisor, another was just starting CDM classes, and the RD only came to the facility once a month. The facility policy stated the dietary department’s day-to-day functions are to be supervised by a qualified dietary manager.
Surveyors found multiple food items in the walk-in cooler, snack cart, and a separate refrigerator that were unlabeled and undated, including desserts, beef tips, rice, ham slices, juices, buns, ice cream, and an open drink. The food temperature log also had missing entries for multiple supper meals, and dietary staff acknowledged the evening shift was not recording food temperatures and that some foods were being stored without proper dating and labeling.
Expired medications and vaccines were found stored in the medication room refrigerator, including IM lorazepam, high-dose influenza vaccine, and influenza vaccine. An LN said nurses were supposed to periodically check for outdated meds, while an Administrative Nurse said the pharmacy consultant removed outdated meds quarterly and that overnight staff checked the refrigerator during temperature checks. The facility could not provide a medication storage policy.
PRN Benadryl Lacked Required Stop Date: A resident with dementia, insomnia, anxiety, and severely impaired cognition had a PRN Benadryl order for insomnia that did not include a stop date or specified duration. The LN and an Administrative Nurse stated the order should have had an automatic 14-day stop date, and the facility’s psychotropic med policy required psychotropics to be clinically indicated and not used as a chemical restraint.
A resident with dementia and urinary retention had an indwelling Foley catheter, but the EMR lacked a current physician order documenting the indication for continued use and the catheter size. Although the chart included catheter care and irrigation orders, an LPN and an administrative nurse could not locate the actual physician order, and the administrative nurse stated the catheter was being used for comfort measures.
A resident with advanced dementia, insomnia, anxiety, and severely impaired cognition had a PRN Benadryl order for insomnia that lacked a stop date. The facility’s monthly pharmacy reviews did not document a pharmacist recommendation for an automatic stop date, and staff stated the pharmacist should have caught the issue during the monthly med review as required by policy.
Failure to Collaborate With Hospice Provider: A resident with advanced dementia, severely impaired cognition, and multiple chronic conditions was receiving hospice services, but the care plan did not identify the hospice provider or other hospice services. Staff interviews showed CNAs were unsure whether the resident was on hospice, an LPN was unaware of any written hospice communication, and no hospice documentation could be found in the record.
Failure to Offer or Document PCV20 Vaccination: The facility failed to offer PCV20 or obtain signed declinations for three residents. One resident had prior pneumococcal vaccines documented, but the record lacked evidence that PCV20 was offered or given. An RN stated immunizations were tracked by the MDS coordinator, no signed declinations were obtained, and residents had to leave the facility to receive the vaccine.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not employ a full-time Certified Dietary Manager (CDM) to supervise meal preparation and kitchen sanitation, risking inadequate nutrition for 36 residents. Dietary Staff BB, who assisted with meal service, was still in training for CDM certification and scheduled to take the test in November. The facility's policy required a licensed CDM for daily dietary department functions, with weekly RD visits during training.
The facility failed to discard expired medications and vaccines, including bisacodyl suppositories and Fluzone vaccines, found in the medication storage room. A CMA was observed retrieving medication from a cart containing a bottle of multivitamins with no expiration date. The facility's policy requires expired drugs to be returned or destroyed, which was not followed.
Dietary staff failed to measure and prepare pureed foods according to standardized recipes, risking impaired nutrition for four residents. Staff admitted to estimating food amounts instead of measuring, contrary to facility policies.
A facility failed to ensure the safe use of a bed rail for a resident with Parkinson's disease and mild cognitive impairment, placing her at risk for injury. The facility did not conduct a comprehensive assessment of the rail's safety, including the risk of entrapment and the space between the rail and mattress. Observations showed the rail was not securely affixed, and the facility's Bed Safety policy was not adequately followed.
A facility failed to ensure a Consultant Pharmacist identified and reported the absence of a 14-day stop date for a resident's PRN lorazepam, used for anxiety. The resident had dementia and severely impaired cognition. The CP's monthly review did not address this irregularity, confirmed by an Administrative Nurse, placing the resident at risk for unnecessary psychotropic medication use.
A facility failed to ensure a 14-day stop date or specified duration for a resident's PRN antianxiety medication, lorazepam, as required. The resident, diagnosed with dementia, major depressive disorder, and anxiety, received lorazepam for anxiety and restlessness without a documented stop date or rationale for continued use. Observations and interviews confirmed the deficiency, and the facility lacked a policy for PRN psychotropic medications, placing the resident at risk for adverse side effects.
Lack of Required RN Coverage
Penalty
Summary
The facility failed to provide RN coverage for eight consecutive hours a day, seven days a week. Review of the nursing schedules for August 2025, September 2025, October 2025, November 2025, December 2025, January 2026, and March 2026 showed no evidence of RN coverage on multiple dates, including 08/04/2025, 08/10/2025, 09/27/2025, 10/04/2025, 10/11/2025, 10/18/2025, 10/19/2025, 10/25/2025, 10/26/2025, 11/08/2025, 11/29/2025, 12/19/2025, 12/28/2025, 01/01/2026, 01/03/2026, 01/24/2026, and 03/08/2026. The facility could not provide verifiable, auditable evidence of RN coverage. On 07/23/2026, Administrative Nurse D stated there was not an RN in the facility on those dates, although she was always on call. On 07/22/2026, Administrative Staff A stated he expected an RN in the building for eight hours a day and said the facility had discussed applying for a nursing waiver and used contract nursing when available. The facility’s Nursing Staff policy stated it would maintain sufficient nursing staff with appropriate competencies and skill sets to provide nursing and related services, with staffing levels based on resident assessments, acuity, diagnoses, and plans of care.
Lack of Full-Time Certified Dietary Manager
Penalty
Summary
The facility failed to provide the services of a full-time certified dietary manager for the 36 residents who received meals from the kitchen. During interviews, Dietary Staff CC stated the facility did not have a Certified Dietary Manager and that she was the kitchen supervisor, while the person taking over the CDM role was on vacation and another dietary staff member had just started taking classes for the CDM. Administrative Staff A stated he was aware the facility did not have a CDM and that the facility did have a person taking the class. Administrative Nurse A stated the Registered Dietician comes to the facility once a month. The facility's Dietary Manager policy dated 2018 stated that the day-to-day functions of the dietary department are under the supervision of a qualified dietary manager.
Unlabeled food items and missing meal temperature logs
Penalty
Summary
The facility failed to follow sanitary dietary standards related to food storage and service. During the initial tour, surveyors observed multiple food items in the walk-in refrigerator and other food storage areas that were wrapped or uncovered but unlabeled and undated, including individual pieces of cake and pie, a steam table pan of beef tips, a steam table pan of rice, a platter of ham slices, opened jugs of apple juice and orange juice, and frosted cinnamon rolls in a snack cart. Outside the dining room area, a white refrigerator also contained two buns, a bucket of ice cream, and an open drink that were unlabeled and undated. Record review showed the food temperature log had no temperatures recorded for multiple supper meals in July. Dietary staff stated the cakes and pies were to be thrown away and acknowledged being unaware that food placed in the cooler for the same day needed to be dated and labeled. Staff also stated the beef tips and rice were for supper, that the ham should have been labeled and dated and placed in the freezer, and that opened juice jugs needed dates. Another dietary staff member stated the evening shift was not recording temperatures of foods and that there had been complaints that supper meal foods were cold. Administrative staff stated the facility did not have a CDM and that the RD came once a month.
Expired Medications and Vaccines Found in Medication Refrigerator
Penalty
Summary
The facility failed to store medications and biologicals in accordance with accepted professional principles when it did not date-check expired or outdated products in the medication room refrigerator. Surveyors observed four vials of IM lorazepam, 20 vials of high-dose influenza vaccine, and 40 vials of influenza vaccine in the refrigerator, all dated 06/2026 and found to be past the date to be used. During interviews, an LN stated the pharmacist came monthly to destroy and remove outdated medication and that nurses were also supposed to periodically check for outdated medication. An Administrative Nurse stated the pharmacy consultant came quarterly to destroy medication, acknowledged the influenza vaccines were outdated and that she was waiting on a return label for credit, and stated she was unaware the lorazepam had expired. She also stated the overnight shift was responsible for checking the refrigerator for expired medication when taking the refrigerator temperature. The facility was unable to provide a medication storage policy when requested.
PRN Benadryl Lacked Required Stop Date
Penalty
Summary
The facility failed to ensure that PRN Benadryl used for its psychotropic properties had a 14-day stop date or a specified duration with supporting physician documentation for R6. R6 had diagnoses including dementia, insomnia, anxiety, atrial fibrillation, hypertension, and urinary retention. The Significant Change MDS dated 06/16/2026 documented a BIMS score of 3, indicating severely impaired cognition, and the CAA dated 06/19/2026 documented advanced dementia and periods of confusion. R6’s care plan included interventions for insomnia, including PRN medication and non-medication approaches such as a back rub, quiet atmosphere, consistent schedule, and hot chocolate. R6’s physician order for Benadryl 25 mg by mouth every four hours as needed for insomnia, dated 06/17/2026, did not include a stop date. On 07/22/2026, an LN stated the Benadryl order should have an automatic stop date after 14 days if used for insomnia, and an Administrative Nurse stated it should have a 14-day stop date and that the pharmacist should have caught it during monthly pharmacy reviews. The facility’s psychotropic medications policy stated residents would not be given psychotropic medications that were not adequately clinically indicated and necessary to treat a specific condition, and that proper processes would be followed to ensure the medication used was appropriate and not considered a chemical restraint.
Missing Physician Order for Foley Catheter
Penalty
Summary
The facility failed to ensure a resident with dementia, insomnia, anxiety, atrial fibrillation, hypertension, and urinary retention had a current physician order with an appropriate indication for the ongoing use of an indwelling Foley catheter, and the record also lacked the catheter size needed for insertion. The resident’s EMR documented that he had an indwelling Foley catheter during the observation period, and the Urinary Incontinence and Indwelling Catheter Care Area Assessment stated the catheter had been in place before admission to hospice for urinary retention. The care plan included catheter care every shift, irrigation as needed, enhanced barrier precautions, protection of catheter tubing from pressure to the skin, and continued use of the Foley catheter with peri care every shift and as needed. The EMR orders showed catheter care every shift, twice a day, and that the Foley catheter could be irrigated as needed, but survey review found no physician order documenting the indication for insertion or the catheter size. A nurse stated the catheter orders should have been under physician orders but could not locate them in the EMR, and she was unsure of the indication or the type and size of catheter ordered. An administrative nurse also could not locate the physician order and stated the catheter was for comfort measures and was never to be changed again. The facility was unable to provide policy-related catheter orders when requested.
Pharmacist Failed to Identify Missing Stop Date for PRN Benadryl
Penalty
Summary
The facility failed to ensure the Consultant Pharmacist identified and reported an irregularity during the monthly drug regimen review for a resident with advanced dementia, insomnia, anxiety, atrial fibrillation, hypertension, and urinary retention. The resident’s EMR, MDS, and CAA documented severely impaired cognition, advanced dementia, periods of confusion, and difficulty sleeping at night. The care plan included interventions for insomnia, including non-medication approaches and as needed medication use. The resident had a physician order for Benadryl 25 mg by mouth every four hours as needed for insomnia, dated 06/17/2026, and the order lacked a stop date. The facility’s Monthly Medication Review records from October 2025 through July 2026 did not document a pharmacist recommendation for an automatic stop date for the Benadryl, even though the medication was being used for insomnia. During interviews, a nurse stated she did not address the monthly pharmacy reviews, and an administrative nurse stated the Benadryl should have had a 14-day stop date and expected the pharmacist to have identified that issue during the monthly review. The facility policy required the consultant licensed pharmacist to review each resident’s drug regimen at admission and at least monthly thereafter, including the resident’s health record.
Failure to Collaborate With Hospice Provider
Penalty
Summary
The facility failed to ensure collaboration with the hospice provider for a resident with advanced dementia and multiple chronic conditions, including insomnia, anxiety, atrial fibrillation, hypertension, and urinary retention. The resident’s EMR documented hospice services, and the Significant Change MDS showed a BIMS score of 3, indicating severely impaired cognition. The resident’s CAA documented advanced dementia and periods of confusion. The care plan included interventions such as hospice-related wound care, anxiety medication, positioning assistance, oral care, fluid access, bowel management, pain management, oxygen as needed, and continued use of a Foley catheter, but it did not include other services provided by hospice or identify the hospice provider. The resident’s EMR also contained an order to admit him to hospice services. During observation, the resident was seen independently transferring from the dining room to the common area and staff provided him water. Interviews showed CNA staff had access to care plan information but could not tell whether the resident was on hospice, stating the nurse would let staff know if a resident was on hospice. An LPN stated she thought hospice staff came weekly and was not aware hospice provided written communication during visits, and she could not find any written documentation from the hospice provider. An administrative nurse stated the facility only contracted with one hospice and that hospice provided weekly nurse and social service visits, but the record review and staff interviews showed the facility lacked documented collaboration with the hospice provider.
Failure to Offer or Document PCV20 Vaccination
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations. Based on record reviews and interviews, the facility failed to offer and provide, or obtain a signed declination for, the Pneumococcal Conjugate Vaccine (PCV20) for three residents: R11, R4, and R25. R11’s clinical record showed receipt of PCV13 on 03/07/2019 and PPV23 on 01/20/2021, but there was no declination for PCV20 and no evidence that PCV20 was offered and administered. R4’s and R25’s clinical records also lacked a declination for PCV20 and lacked evidence that the vaccine was offered and administered. During interview, Administrative Nurse D stated immunizations were tracked by the MDS coordinator, that she did not obtain a signed declination for PCV20, and that she documented in the quarterly MDS progress note when a resident declined the vaccine. She also stated R11 had not received the vaccine because his wife did not want him to leave the facility, and that residents had to leave the facility to receive the vaccines.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Lack of Certified Dietary Manager in Facility
Penalty
Summary
The facility failed to employ a full-time Certified Dietary Manager (CDM) to oversee the preparation of meals and sanitation in the kitchen, which placed 36 residents at risk for inadequate nutrition. During an observation on September 10, 2024, at 12:00 PM, Dietary Staff (DS) BB was seen assisting with the noon meal service. Later, at 12:45 PM, DS BB mentioned that the previous Registered Dietician (RD) had helped her with training related to the CDM certification, and she had completed the courses but was scheduled to take the test in November 2024. The facility's policy required the dietary manager to be a certified dietary manager licensed by the state, responsible for the day-to-day functions of the dietary department, with the RD providing weekly on-site visits during the CDM course completion.
Failure to Discard Expired Medications and Vaccines
Penalty
Summary
The facility failed to properly store and manage medications and biologicals, as evidenced by the presence of expired medications and vaccines. During an observation, a Certified Medication Aide was found retrieving medication from a cart that contained a bottle of multivitamins with no expiration date. Additionally, a Licensed Nurse discovered expired bisacodyl suppositories and Fluzone vaccines in the medication storage room's refrigerator. These items had expiration dates ranging from May 2024 to July 2024, and the nurse confirmed the expiration dates. The facility's policy, dated April 2014, mandates that expired or improperly labeled drugs should be returned to the pharmacy or destroyed, which was not adhered to in this instance.
Failure to Measure and Prepare Pureed Foods Properly
Penalty
Summary
The facility failed to provide food prepared by methods that conserve nutritive value, flavor, and appearance for four residents on a pureed diet. During an observation, Dietary Staff (DS) CC was seen preparing pureed foods without measuring the amounts of meatloaf, scalloped potatoes, and squash. DS CC added vegetable juice to these foods before pureeing but did not measure the servings when placing them in cups for each resident. DS CC admitted to not having recipes for the pureed foods and stated she estimated the amounts instead of measuring. Dietary Staff (DS) BB confirmed that recipes should be followed for pureed foods and portions should be measured before the pureeing process, as taught by the Registered Dietician. The facility's policies required the use of standardized recipes and recommended specific liquids for pureeing foods. The failure to adhere to these guidelines placed the affected residents at risk for impaired nutrition, as the food was not prepared in a manner that conserved its nutritive value, flavor, and appearance.
Failure to Ensure Safe Use of Bed Rail
Penalty
Summary
The facility failed to ensure the safe use of a bed rail for a resident, identified as R4, which placed her at risk for accident or injury. R4's medical history included Parkinson's disease, spinal stenosis, and mild cognitive impairment, requiring assistance with bed mobility and transfers. Despite these conditions, the facility's documentation lacked a comprehensive assessment of the side rail's safety, specifically regarding the risk of entrapment and the space between the rail and the mattress. The facility's records showed that a Side Rail Assessment was completed upon R4's admission, noting the need for side rails due to her weakness and balance issues, as well as a family request. However, the assessment did not include an evaluation by physical or occupational therapy to determine the appropriate type of rail and its usage. Additionally, the maintenance check conducted did not address the rail's openings or the area between the rail and mattress, which are critical for preventing entrapment. Observations revealed that the side rail on R4's bed had a large opening and was not securely affixed, allowing it to move easily. This was confirmed by the facility's administrative nurse, who acknowledged the lack of further assessment for the side rail's use. The facility's Bed Safety policy emphasized the importance of assessing the resident's sleeping environment and ensuring bed rails are properly installed, but these procedures were not adequately followed for R4, leading to the identified deficiency.
Failure to Identify and Report Medication Irregularity
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported the absence of a 14-day stop date or specified duration for a resident's as-needed (PRN) antianxiety medication, lorazepam. The resident, identified as R10, had diagnoses of dementia, major depressive disorder, and anxiety, with severely impaired cognition. The resident's care plan documented the use of lorazepam for anxiety and restlessness, but the physician's order lacked a stop date or rationale for extended use. The CP's monthly review did not identify this irregularity, which was confirmed by the Administrative Nurse. The facility's policy required the CP to provide consultation on all aspects of pharmacy services, including identifying medication irregularities. However, the CP's review for R10 did not include a recommendation for a 14-day stop date or a rationale for continued use of lorazepam. This oversight placed the resident at risk for unnecessary psychotropic medication use. The facility's failure to adhere to its policy and ensure proper medication management was evident in the lack of communication and documentation regarding the PRN lorazepam order.
Failure to Ensure Stop Date for PRN Antianxiety Medication
Penalty
Summary
The facility failed to ensure a 14-day stop date or a specified duration with rationale for a resident's ongoing as-needed (PRN) antianxiety medication, lorazepam. This oversight was identified during a review of the resident's electronic health record (EHR), which revealed diagnoses of dementia, major depressive disorder, and anxiety. The resident's care plan documented the use of lorazepam for anxiety and restlessness, but the physician's order lacked a stop date or a specified duration with a rationale for the extended use of the medication. Observations and interviews confirmed the deficiency. On one occasion, the resident was observed receiving lorazepam PRN without a documented stop date or rationale for continued use. An administrative nurse verified the absence of a 14-day stop date or reason for the continued use of the medication. Additionally, the facility did not provide a policy related to PRN psychotropic medications, which contributed to the failure to ensure the resident was free of unnecessary psychotropic drugs, placing the resident at risk for adverse side effects.
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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.
Illustrative
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Nursing homes near La Crosse
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Via Christi Village Hays Ks Llc | 24.2 mi | ★★★★★ | 4 | 0 |
| Good Samaritan - Hays | 24.7 mi | ★★★★★ | 1 | 0 |
| Diversicare Of Larned | 25.9 mi | ★★★★★ | 11 | 0 |
| Medicalodges Great Bend | 28.7 mi | ★★★★★ | 24 | 0 |
| Azria Health Great Bend | 30.5 mi | ★★★★★ | 1 | 0 |
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