Above 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 Meade District Hosp Ltcu Dba Lone Tree Retirement during CMS and state inspections, most recent first.
The facility did not assign a qualified Infection Preventionist (IP) to manage its infection prevention and control program. The staff member acting as IP had completed a relevant training course but lacked a health-related degree, and another nurse assisting with IP duties was still in the process of obtaining certification. This did not meet the facility's policy requiring the IP to have primary training in a health-related field.
Surveyors identified multiple unsanitary food storage and preparation practices, including food items stored on the floor, unsealed and unlabeled food in storage areas, and kitchen equipment with visible debris and damage. Staff interviews confirmed expectations for proper labeling, sealing, and equipment maintenance, but these were not followed, resulting in deficiencies in food safety and sanitation.
Surveyors observed that kitchen garbage cans were repeatedly left uncovered, with staff confirming that lids were rarely used despite facility policy requiring covered containers. The issue persisted over multiple days, and administrative staff acknowledged that garbage cans should always have lids.
The facility did not ensure that each resident received an accurate assessment, resulting in incomplete or incorrect evaluations necessary for determining appropriate care and services.
Staff did not follow Enhanced Barrier Precautions or proper hand hygiene when providing care to a resident with a Stage 3 pressure injury and her roommate, including failing to wear gowns and not sanitizing hands between glove changes or between residents. Additionally, several staff delivered food with their thumbs touching the eating surface of plates, and shared equipment was not sanitized between uses, contrary to facility policy.
A resident with Alzheimer's disease and dementia, dependent on staff for transfers, was connected to a mechanical lift in full view of the hallway because a CNA left the door and privacy curtain open. Staff interviews confirmed that privacy measures should have been in place during the procedure, as required by facility policy.
A resident discharged to the community did not receive a written discharge summary or recapitulation of stay. Although the EHR included documentation of discharge planning and communication with the physician, the required summary was missing, and the provided interdisciplinary evaluation was incomplete. Staff interviews confirmed the absence of the necessary documentation, and the facility's policies did not address this requirement.
The facility did not submit accurate PBJ staffing data to CMS, as the time-keeping system automatically deducted a 30-minute lunch period from nurses' hours, resulting in reported gaps in 24-hour licensed nursing coverage, despite schedules and payroll confirming continuous coverage. No policy for PBJ reporting was provided.
A cognitively impaired resident with vascular dementia and severe cognitive impairment eloped from a facility due to inadequate supervision and lack of timely interventions. The resident displayed increased wandering and exit-seeking behaviors, which were documented but not addressed with sufficient measures. The resident exited the facility when visitors held the door open, remaining unsupervised until noticed by a CNA.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) to oversee the Infection Prevention and Control Program (IPCP) for its 33 residents. Administrative Staff A, who was acting as the IP, had completed a Nursing Home Infection Prevention Training Course but did not possess a health-related degree, holding instead a bachelor's degree in Aging Sociology. Administrative Nurse D was assisting with IP duties but had not yet completed the required IP certification. Interviews revealed that there was a lack of understanding among staff regarding the qualifications necessary for the IP role. The facility's own infection control policy required the IP to have primary training in nursing, medical technology, microbiology, epidemiology, or a related field, which was not met by the current designee.
Food Storage and Sanitation Deficiencies in Kitchen
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage, preparation, and serving practices. In the dry storage area, several food items, including cases of soda cans and a large bag of flour, were stored directly on the floor. There were also unsealed bags of marshmallows, instant mashed potatoes, and a container of pinto beans not properly sealed. Several bottles of spices lacked both an opened date and expiration date. In the walk-in cooler, containers of drinks with straws were found without dates, and several food items such as broccoli, onions, pizza, shredded cheese, and mixed fruit were unsealed or undated. The walk-in freezer contained unsealed bags of biscuits, waffles, ground beef, and an unlabeled plastic container. Two refrigerators in the kitchen had unsealed roast beef and an open gallon of milk with no date. Additionally, several cooking pans had black debris, one frying pan was dented, and four cutting boards had multiple scratches. Interviews with the Certified Dietary Manager (CDM) and administrative staff confirmed that staff were expected to keep items off the floor, label and seal all food items, and maintain kitchen equipment in good working order. The facility's policies required proper storage, labeling, and dating of food items, as well as maintaining clean and organized kitchens and equipment. However, the observed practices did not align with these policies, resulting in food being stored and prepared under unsanitary conditions.
Improper Disposal and Maintenance of Kitchen Garbage
Penalty
Summary
The facility failed to properly maintain and dispose of kitchen garbage and refuse, as evidenced by multiple observations of three garbage cans in the kitchen without lids over a two-day period. Despite the presence of lids in the kitchen, staff reported that the garbage cans rarely had lids placed on them. The Certified Dietary Manager confirmed that garbage cans should be covered, and administrative staff stated an expectation that all garbage cans in the kitchen have proper lids at all times. The facility's waste disposal policy required daily and as-needed disposal of garbage and the use of sealed containers outside the premises, but no specific waste management policy was provided.
Failure to Ensure Accurate Resident Assessments
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure that each resident received an accurate assessment. The report notes that assessments were not completed accurately, which is required to determine the appropriate care and services for residents. Specific details about the residents involved, their medical history, or their condition at the time of the deficiency are not provided in the report. The deficiency centers on the inaccuracy of resident assessments, which are essential for planning and delivering individualized care.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene During Resident Care and Food Service
Penalty
Summary
Staff failed to utilize Enhanced Barrier Precautions (EBP) and proper hand hygiene during direct care of a resident with a Stage 3 pressure injury. Certified Nurse Aides (CNAs) provided peri-care to the resident without donning gowns, as required by EBP protocols, and only wore gloves. During the care process, one CNA changed gloves without performing hand hygiene, and both CNAs assisted the resident's roommate with peri-care immediately after, again without performing hand hygiene between residents. After completing care, the CNAs removed their gloves but did not perform hand hygiene before exiting the room. One CNA then handled a mechanical lift, entered another resident's room, and performed tasks without hand hygiene, only sanitizing hands after returning the lift to storage. The mechanical lift was not cleaned before being placed in the common storage area. Additionally, multiple staff members, including Certified Medication Aides and CNAs, delivered food to residents in the dining room with their thumbs touching the eating surface of the plates, contrary to infection control expectations. Interviews with staff and review of facility policies confirmed that staff were expected to use proper PPE, perform hand hygiene before and after resident contact, and sanitize shared equipment between uses. The facility's policies also required the use of utensils, not bare hands, when serving food.
Failure to Provide Privacy During Resident Transfer
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease and dementia, who was dependent on staff for transfers and had moderately impaired cognition, received care without appropriate privacy measures. During an observation, a Certified Nurse Aide (CNA) entered the resident's room with a mechanical lift, left the door to the hallway open, and did not draw the privacy curtain. The resident was connected to the mechanical lift in full view from the hallway while the CNA waited for additional assistance. Staff interviews confirmed that the door and privacy curtain should have been closed during the use of the mechanical lift to maintain the resident's dignity and privacy. The facility's policy also required that residents receive care in a manner that enhances and maintains their dignity and respect, including closing doors and drawing curtains during care activities. The failure to provide privacy during the transfer process constituted a lack of dignified care for the resident.
Failure to Provide Written Discharge Summary and Recapitulation of Stay
Penalty
Summary
The facility failed to provide a written discharge summary or recapitulation of the stay for a resident who was discharged to the community. The resident's electronic health record (EHR) documented multiple communications and orders regarding the discharge, including physician orders, progress notes about discharge planning, and documentation that the resident's family assisted with moving belongings. Staff documented a discharge meeting where the medication list was reviewed and noted that the resident had independently arranged follow-up appointments and transportation. However, the EHR lacked evidence that a written discharge summary or recapitulation of the stay was provided to the resident or their family. A printed copy of a Planned Discharge - Interdisciplinary evaluation was later provided, but it was incomplete and did not include required elements such as the resident's condition at admission, discharge destination, to whom the resident was released, disposition of medications or personal possessions, aftercare instructions, or a summary of the stay. Interviews with staff confirmed that the recapitulation should have been present in the medical record, and the resident confirmed she did not receive a written discharge summary. The facility's policies did not address the requirement to provide a written discharge summary or recapitulation of the stay.
Failure to Accurately Report Nursing Coverage in PBJ Data
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS through Payroll-Based Journaling (PBJ) as required. Although the PBJ Staffing Data Report indicated that there was not 24-hour licensed nursing coverage on several dates across two fiscal quarters, a review of the facility's nursing schedule and payroll data confirmed that 24-hour nursing coverage was actually provided on those dates. The discrepancy was due to the facility's time-keeping system, which automatically deducted a 30-minute lunch period from the nurses' recorded hours, even though the nurses remained in the building during that time. The facility did not provide a policy related to PBJ reporting.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for a cognitively impaired resident, identified as an elopement risk. The resident, diagnosed with vascular dementia and severe cognitive impairment, displayed increased wandering and exit-seeking behaviors over several days. Despite these behaviors, the facility did not implement sufficient interventions to prevent the resident from leaving the facility unsupervised. On multiple occasions, the resident attempted to exit the facility, expressing a desire to leave and displaying agitation. The care plan for the resident lacked specific interventions related to wandering and exit-seeking until after the resident successfully eloped. The facility's staff were aware of the resident's behaviors, as documented in progress notes, but failed to take timely action to mitigate the risk of elopement. The deficiency was highlighted when the resident exited the facility without staff knowledge after visitors held the door open. The resident remained outside unsupervised until noticed by a CNA. The facility's policy required a Wander Guard for residents with exit-seeking behaviors, but this was not applied until after the elopement occurred.
Removal Plan
- Electronic communication message sent out via electronic medical record communication board.
- Staff placed a Wander Guard to R2's right ankle and posted signage at the front door stating 'Please do not let anyone out the doors. Check with charge nurse at Nurse's Station.'
- R2's care plan updated to include the Wander Guard, Wander Risk Assessment completed, and the Medical Director notified.
- A meeting was held with CNA's, CMA's and Licensed Nurses to educate on Elopement and Behaviors.
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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 Meade
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fowler Residential Care | 10.1 mi | ★★★★★ | 0 | 0 |
| Minneola District Hospital Ltcu | 20.6 mi | ★★★★★ | 0 | 0 |
| Bethel Home | 22 mi | ★★★★★ | 0 | 0 |
| Beaver County Nursing Home | 34.4 mi | ★★★★★ | 0 | 0 |
| Sunporch Of Dodge City | 35.1 mi | ★★★★★ | 1 | 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.