Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Mcpherson Operator, Llc during CMS and state inspections, most recent first.
A resident with multiple health conditions and a high risk for falls independently accessed an unsecured shower room after staff failed to ensure the door was properly closed. The resident, who required assistance with bathing and was known to self-transfer, entered the shower room unsupervised, fell, and sustained a fractured wrist. The incident occurred because the shower room door, though equipped with a keypad lock, was not fully shut, allowing entry without staff assistance.
The facility did not consistently record food temperatures at mealtimes, nor did it document refrigerator and freezer temperatures during the evening shift. Logs were found to be incomplete or filled in with identical, potentially inaccurate values. Staff also failed to regularly document the chemical PPM of sanitizing solutions, and there were observations of dirty dishes being used for meal service. These actions were not in accordance with the facility's policies for safe food handling and sanitation.
A Certified Medication Aide was allowed to work without a completed criminal background check, contrary to facility policy and state guidelines. This oversight meant the facility could not confirm whether the employee had any history of abuse, neglect, exploitation, or related offenses before granting them access to residents.
Staff failed to immediately report an incident where a resident with dementia and significant care needs was physically contacted by another resident during a supervised smoke break. The certified medication aide who witnessed the event delayed reporting it to the charge nurse, contrary to facility policy requiring prompt notification of suspected abuse or mistreatment.
A resident receiving hospice care for multiple chronic conditions did not have a facility care plan that included specific details coordinating with the hospice plan, such as visit frequency, equipment, medications, and hospice contact information, despite facility policy requiring this integration. Staff confirmed the lack of coordinated care planning.
Failure to Secure Shower Room Door Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to ensure that a shower room door was properly secured, resulting in a resident entering the room unsupervised and sustaining a fall that led to a fractured wrist. The resident involved had multiple diagnoses, including COPD, osteoporosis, delusional disorder, anxiety, and muscle weakness. She was assessed as having intact cognition but required partial to moderate assistance with most activities of daily living, including bathing and shower transfers. Her care plan noted a history of not waiting for assistance, self-transferring, and sometimes refusing staff help with ADLs. She was also identified as high risk for falls, with specific interventions outlined in her care plan, such as frequent staff checks and the use of non-slip materials. On the day of the incident, the resident requested a shower but was told by staff that assistance would be provided later. Despite this, she independently accessed the shower room, which was supposed to be locked but was left unsecured because the door was not fully closed. The resident entered the shower room, undressed, and attempted to shower without assistance. Staff discovered her on the floor of the shower room, having fallen and fractured her left wrist. The resident's wheelchair was found in the doorway, and her oxygen tank remained on her walker in her room across the hall. Interviews and documentation confirmed that the shower room door, although equipped with a keypad lock, was not pulled shut, allowing the resident to enter unassisted. The facility's policy required that accident hazards be minimized and that supervision and assistance be provided according to individual resident needs and environmental risks. The failure to ensure the shower room door was properly secured directly led to the resident's unsupervised access and subsequent injury.
Failure to Document Food and Equipment Safety Measures
Penalty
Summary
The facility failed to consistently measure and record food temperatures at mealtimes and to document daily refrigerator and freezer temperatures during the evening shift. Observations revealed that temperature logs for the refrigerator and freezer were missing entries for multiple days on the evening shift, and when these logs were later filled in, the entries contained identical temperatures for each day, raising concerns about their accuracy. Dietary staff confirmed that temperatures were supposed to be recorded daily, both in the morning and evening, and that meal temperatures were to be taken for every meal served. However, the logs lacked documentation for numerous meals throughout the month. Additionally, staff were observed plating meals using dishes that had dried food particles, and there were resident complaints about dirty dishes. The facility also failed to record the chemical Parts Per Million (PPM) of the sanitizing solution in the Sanitizer Bucket Log three times a day as required. Review of the logs showed frequent omissions in documenting the PPM levels for the morning, afternoon, and evening shifts. Staff acknowledged the lack of documentation and stated that recording the PPM was necessary to ensure proper sanitization. Facility policies required that food be prepared and served in accordance with safe food handling practices, and that equipment and utensils be properly sanitized, but these procedures were not consistently followed.
Failure to Complete Required Criminal Background Check for Employee
Penalty
Summary
The facility failed to conduct a required criminal background check for a Certified Medication Aide (CMA) who had been working in the facility since their hire date. During a review of staffing records, the facility was unable to provide evidence that a criminal background check had been completed for this employee. The CMA had been allowed access to residents without confirmation of their eligibility, specifically whether they had any history of abuse, neglect, exploitation, misappropriation of property, or mistreatment as determined by a court of law. The facility's own Abuse Prevention Program policy required that background checks be completed per state guidelines for all employees prior to employment, and that documentation of such checks be maintained. The policy also specified that individuals with findings of abuse or related offenses should not be employed. Despite these requirements, the lack of a completed background check for the CMA meant the facility could not ensure compliance with its own policies or state regulations regarding the prevention of abuse, neglect, and theft.
Failure to Immediately Report Suspected Resident-to-Resident Abuse
Penalty
Summary
Facility staff failed to immediately report an incident involving two residents, one of whom had dementia, osteoporosis, muscle weakness, and required extensive assistance with activities of daily living. The incident occurred when one resident made contact with another's shoulder in an attempt to maneuver around her prior to a supervised smoke break. The certified medication aide (CMA) who witnessed the event did not report it to the charge nurse until nearly two hours later, despite facility policy requiring immediate reporting of suspected abuse or mistreatment. The resident who was contacted had a care plan indicating the need for close supervision due to cognitive impairment, physical limitations, and behavioral issues related to dementia and anxiety. The care plan also specified interventions for supervised smoking and behavioral management to protect the safety of all residents. At the time of the incident, the resident was receiving hospice services and was on multiple medications, including antidepressants, antipsychotics, and opioids. Facility policy clearly outlined the responsibility of all staff to promptly report any suspected abuse, neglect, or mistreatment to facility management, with immediate examination and documentation required. In this case, the delay in reporting by the CMA resulted in a failure to follow established procedures, placing the resident at risk for ongoing mistreatment and inadequate supervision.
Failure to Coordinate Hospice Services in Resident Care Plan
Penalty
Summary
The facility failed to ensure coordinated care and services between the facility and hospice for a resident receiving end-of-life care. The resident, who had diagnoses including dementia, osteoporosis, muscle weakness, and sarcopenia, was documented as requiring extensive staff assistance with activities of daily living and had bilateral lower extremity contractures. The resident's care plan noted the need for monitoring skin breakdown and immobility, and the hospice care plan indicated the provision of comfort measures and medication administration. However, the facility's care plan lacked specific instructions regarding the coordination with hospice, such as the frequency and type of hospice support visits, supplies and medical equipment provided by hospice, medications covered by hospice, and hospice contact information. Record review and staff interview confirmed that the facility did not include detailed information from the hospice plan of care in the resident's facility care plan. The facility's own policy required identification in writing of the services hospice would provide and for these to be addressed in the resident's person-centered care plan. Despite this, the care plan did not reflect the necessary coordination, and the administrative nurse verified the absence of this information.
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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 Mcpherson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Cedars | 1.2 mi | ★★★★★ | 9 | 0 |
| Pleasant View Home | 12.4 mi | ★★★★★ | 0 | 0 |
| Bethany Home Association | 12.8 mi | ★★★★★ | 2 | 0 |
| Riverview Estates | 14.3 mi | ★★★★★ | 0 | 0 |
| Moundridge Manor | 15.1 mi | ★★★★★ | 0 | 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.