Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Pratt Health And Rehab during CMS and state inspections, most recent first.
Failure to Use EBP for Wound Care and Incomplete Legionella Water Management Program: A resident with dementia, DM, and a Stage 3 coccyx pressure ulcer received wound care from an LPN who wore gloves but not a gown, despite the facility’s EBP policy calling for gown and glove use during high-contact care for residents with wounds. The facility also lacked a documented Legionella water management program mapping the water flow system, even though water testing had been performed and no Legionella was detected.
Failure to issue NOMNCs for three residents receiving Medicare-covered skilled services. Record review showed that the residents’ Part A episodes ended, but the clinical record and facility-provided information lacked evidence that the required SNF NOMNCs were given to the residents or their representatives. An Administrative Nurse provided ABN forms, but no NOMNCs, and stated the notices were missed because of personnel changes in the department that handled them.
A facility failed to provide two residents and their representatives with complete written transfer notices that included appeal rights and State LTC Ombudsman information when the residents were sent to the hospital. One resident’s record also lacked evidence of transfer notification and ombudsman notification for hospital transfers, and another resident’s record lacked proof of a complete discharge summary and recapitulation of stay upon discharge.
A resident with diabetes, impaired mobility, and on anticoagulants was transported in a facility van without being properly secured with a seatbelt by a CNA. After the vehicle began moving, the CNA realized the error, stopped the van, and the resident fell from the wheelchair, sustaining minor injuries. The incident was confirmed by documentation and witness statements, and the facility's policy for safe transport was not followed.
A resident with severe cognitive impairment was observed in bed with only a brief on, exposing himself to others. Staff confirmed difficulties in keeping the resident covered, and the room lacked a privacy curtain. The care plan and facility policy on dignity were not effectively followed.
The facility failed to revise care plans for two residents. One resident, with Alzheimer's disease, was transported in a wheelchair without foot pedals, despite needing them. Another resident, with severe cognitive impairment, was found unsafe to self-administer medications, but the care plan and MAR were not updated. Staff confirmed these oversights, violating facility policy requiring periodic care plan reviews.
The facility failed to ensure that a dependent resident received appropriate facial hair grooming. Despite the care plan indicating the need for extensive assistance with personal hygiene, the resident had several days' growth of facial hair and did not receive a shave even after a shower provided by hospice staff. This lack of grooming interfered with the resident's eating and did not adhere to the facility's policy on ensuring resident privacy and dignity.
A facility failed to provide a sanitary dressing change for a resident's venous ulcer. The resident, with severely impaired cognitive status, developed cellulitis and blisters on her left lower extremity. The licensed nurse placed wound care supplies directly on the floor and performed the dressing change unsanitarily. The facility lacked a policy for the application of an Unna boot, and the wound care guidelines were not followed.
A resident with diabetes and moderate cognitive impairment had his prescription glasses broken and was not provided with appropriate vision care. Despite being aware of the issue, the facility staff did not ensure the resident saw an eye doctor, impacting his well-being.
The facility failed to safely transport a resident in his wheelchair by not using foot pedals, causing his shoed feet to skim the floor. Despite the availability of foot pedals in the resident's room, staff did not use them, citing that the resident sometimes propelled himself and the pedals could be a tripping hazard. This action was against the facility's policy and expectations for safe resident transport.
The facility failed to ensure timely monitoring for adverse effects of antipsychotic medications for three residents. Delays in conducting the Abnormal Involuntary Movement Scale (AIMS) tests were noted, with one resident's test conducted 14 days after starting the medication, another's seven months later, and a third's 21 days later. The facility also lacked a policy for timely AIMS assessments.
A facility failed to properly dispose of a used Fentanyl patch after it was removed from a resident. A Licensed Nurse threw the patch into the resident's trash can, contrary to facility policy, which requires special disposal methods.
A facility failed to provide a sanitary dressing change for a resident with venous ulcers. The resident, with a history of chronic embolism and severely impaired cognitive status, had unsanitary wound care performed by a licensed nurse who placed dressing supplies directly on the floor. The care plan lacked timely wound care instructions, and staff did not follow proper infection control protocols.
Failure to Use EBP for Wound Care and Incomplete Legionella Water Management Program
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions for a resident with a Stage 3 pressure ulcer to the coccyx who required daily wound care. The resident had diagnoses including dementia, diabetes mellitus, generalized anxiety disorder, a cardiac murmur, and hypertension, and the Quarterly MDS documented severe cognitive impairment and an unhealed Stage 3 pressure injury not present on admission. The care plan directed daily wound care, nutritional monitoring, turning and repositioning at least every two hours, weekly wound monitoring, and use of a therapeutic mattress. The wound care consultant documented the Stage 3 midline coccyx ulcer, noted slough that was debrided, and ordered hydrogel and foam dressing treatment. During observation, the resident was on a low air mattress in a low bed position, and a nurse provided wound care while wearing gloves but not a gown. The facility also failed to complete a water management program for Legionella disease. Maintenance staff verified there was no mapping of the facility water flow system, including entering points, flow direction, areas of potential water collection, or the hot water system. Water samples had been tested from the kitchen and from each wing, with unspecified locations sent for Legionella detection, and the report documented no Legionella detected. The facility’s policy stated that it maintains its water supply in accordance with CDC, HICPAC, and FDA recommendations and that the community will demonstrate measures to minimize risk through a documented water management program.
Failure to Issue Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-coverage (NOMNC) to Resident 8, Resident 10, and Resident 17, or their representatives, when skilled services ended. Survey review found that the facility had a census of 38 residents and that three residents were reviewed for Medicare liability notices. Record review showed that Resident 8’s Medicare Part A episode began on 10/23/25 and ended on 01/09/26, Resident 10’s episode began on 06/27/25 and ended on 08/21/25, and Resident 17’s episode began on 05/03/25 and ended on 07/22/25. For each of these residents, the clinical record and facility-provided information lacked evidence that a SNF NOMNC was issued as required. On 03/16/26 at 02:28 PM, Administrative Nurse D provided Skilled Nursing Facility Advanced Beneficiary Notice (ABN) forms for the three residents, but no NOMNC notices were available. Administrative Nurse D stated that the residents or their representatives had not received a NOMNC because of personnel changes in the department that handled the notices. The facility’s Beneficiary Notices policy, dated 07/2025, stated that a Medicare beneficiary has the right to have Medicare determine whether skilled services will not be covered, and that a NOMNC is prepared and given at least three days before the end of the Medicare Part A stay or when all Part B therapies are ending.
Missing transfer notices, ombudsman notification, and discharge documentation
Penalty
Summary
The facility failed to ensure that Resident 29 and Resident 40, and their representatives, were provided with written transfer notifications that included a statement of appeal rights and the State Long-Term Care Ombudsman information when they were transferred to the hospital. For Resident 29, the record showed an unplanned discharge to an acute hospital with return anticipated, and the notice of transfer form provided to the representative lacked the required appeal-rights information and ombudsman contact information. The record also lacked evidence of written notification of transfer for one hospital transfer, and the facility could not provide evidence that the State Ombudsman was notified of Resident 29’s transfers to the hospital on the dates documented in the record. Resident 40’s record also showed an unplanned discharge to an acute hospital with return anticipated. The notice of transfer form provided to the resident’s representative lacked the required statement of appeal rights, including the name, address, and telephone number of the entity receiving appeal requests, as well as information on how to obtain an appeal form and assistance with the appeal hearing request. The form also lacked the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman. Resident 40’s record further lacked proof that a discharge summary and recapitulation of stay were completed upon discharge. Social Services documentation noted that the resident’s guardian and others removed personal belongings from the facility, and the guardian planned to return for remaining items. During interview, Social Services stated the ombudsman was not notified at the time of transfer and that the facility notified ombudsmen at the end of the month if a resident’s bed hold was released. Social Services also stated that a discharge summary had been completed for Resident 40, but it did not include all required information or the recapitulation of the stay.
Resident Injury Due to Failure to Secure Wheelchair During Van Transport
Penalty
Summary
A deficiency occurred when a Certified Nurse Aide (CNA) failed to ensure a resident was safely secured in a facility van before operating the vehicle. The CNA began driving the van with the resident, who used a wheelchair and required staff assistance for transfers, but did not have the resident's seatbelt fastened. After traveling approximately 500 feet at a speed of 10-12 mph, the CNA realized the seatbelt was not secured and stopped the vehicle, at which point the resident fell from the wheelchair onto the floor of the van. The resident involved had a medical history including diabetes mellitus type 2, long-term use of anticoagulants, impaired gait, and required assistance with transfers. The resident's care plan and assessments documented a risk for falls and dependence on staff for safe mobility. During the incident, the resident sustained a skin tear to the left elbow, bruising to the left eye, and an abrasion with bruising to the left side of the scalp. Hospital staff assessed the resident at the scene and found no major injuries reported by the resident, who declined further treatment in the emergency department. Documentation and witness statements confirmed that the CNA forgot to secure the seatbelt and that the resident fell as a result. The facility's policy required residents to be transported in a safe manner and secured per procedure, which was not followed in this instance. The failure to ensure the resident was safely secured in the van before transport constituted a deficiency and resulted in immediate jeopardy to the resident's health and safety.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of a resident diagnosed with schizoaffective disorder and Alzheimer's disease, who was observed in bed with only a brief on, exposing himself to residents, staff, and visitors passing by his room. The resident's electronic medical record indicated severe cognitive impairment and dependency on staff for activities of daily living. Observations on two separate occasions revealed the resident in bed with his sheet tangled and not covering his body, and the room lacked a privacy curtain. Interviews with staff confirmed that the resident frequently moved his legs about in bed, making it difficult to keep him covered, and that he was typically the last resident to be assisted in the morning. The resident's care plan instructed staff to keep his blankets and sheets tucked at the foot of the bed to prevent him from becoming tangled, but this was not effectively implemented. The facility's policy on the exercise of rights, which includes ensuring resident privacy and dignity, was not adhered to in this case. An administrative nurse stated that she would expect staff to clothe the resident with pants to prevent exposure, indicating a failure to follow through with appropriate measures to maintain the resident's dignity.
Failure to Revise Care Plans for Two Residents
Penalty
Summary
The facility failed to revise the care plan with effective interventions for two residents. Resident 12, diagnosed with Alzheimer's disease and severe cognitive impairment, used a wheelchair for mobility and required substantial assistance. Despite this, the care plan did not include instructions for the use of foot pedals while propelling the resident in his wheelchair. Observations on multiple occasions showed that the resident's feet skimmed the floor during transport, and staff confirmed that foot pedals were not used, even though they were available in the resident's room. The facility's policy required periodic review and updating of care plans, which was not followed in this case. Resident 18, with severe cognitive impairment and multiple diagnoses including chronic embolism and paranoid personality, was initially allowed to self-administer medications with nursing staff setup. However, the resident began requesting medications crushed in applesauce and was found to have medications left in her room, indicating she was no longer safe to self-administer. Despite this change in condition, the care plan and Medication Administration Record (MAR) were not updated to reflect the new instructions for medication administration. Interviews with staff confirmed that the resident's care plan was not revised to ensure compliance with prescribed medications. The facility's failure to review and revise the care plans for these residents led to deficiencies in their care. The policies in place required periodic review and updating of care plans when there was a change in the resident's condition, but these were not adhered to, resulting in inadequate care interventions for both residents.
Failure to Provide Facial Hair Grooming for Dependent Resident
Penalty
Summary
The facility failed to ensure that Resident 28 received appropriate facial hair grooming opportunities. The resident, who has diagnoses including schizoaffective disorder and Alzheimer's disease, was assessed with severely impaired cognitive function and was dependent on staff for activities of daily living. Despite the care plan indicating the need for extensive assistance with personal hygiene, observations over several days revealed that the resident had several days' growth of facial hair and did not receive a shave even after a shower provided by hospice staff. Interviews with staff confirmed that the resident had not been shaved since 04/12/24, and there was a lack of clarity on why hospice staff did not provide shaving. The resident's facial hair interfered with his eating, as observed when cereal dripped down his chin into the stubble due to his continuous tongue thrusting outward. The facility's policy on the exercise of rights, dated 09/2023, instructed staff to ensure resident privacy and dignity by grooming them as they wish to be groomed. However, the facility did not adhere to this policy, resulting in the resident not receiving the necessary shaving opportunities to maintain clean facial hygiene and a groomed appearance. This deficiency was highlighted by the observations and interviews conducted during the survey, indicating a failure to provide adequate personal hygiene care for the dependent resident.
Failure to Provide Sanitary Dressing Change for Resident's Venous Ulcer
Penalty
Summary
The facility failed to monitor and provide a sanitary dressing change for a resident's venous ulcer. The resident, who had a severely impaired cognitive status and was at risk for skin breakdown, developed cellulitis and blisters on her left lower extremity. The physician instructed staff to administer antibiotics and perform specific wound care, including the application of an Unna boot. However, the medical record lacked measurements and descriptions of the blisters, and the care plan did not include wound care instructions until six days after the initial diagnosis of cellulitis. During an observation, a licensed nurse placed wound care supplies directly on the floor without a sanitary barrier and performed the dressing change in an unsanitary manner. Interviews with the licensed nurse and administrative nurse confirmed that the supplies should have been placed on a clean barrier and that the facility lacked a policy for the application of an Unna boot. The facility's policy on wound care guidelines was not followed, leading to the deficiency in providing appropriate and sanitary wound care for the resident's condition.
Failure to Provide Vision Care
Penalty
Summary
The facility failed to ensure that a resident received necessary vision care. The resident, who has diagnoses including diabetes and major depressive disorder, was assessed with moderate cognitive impairment and had adequate vision with corrective lenses. However, the resident's glasses were broken after being stepped on by another resident, and the replacement glasses were not his prescription, impairing his vision. Despite the resident's need to see an eye doctor, he believed he could not due to insurance issues. The facility staff were aware of the broken glasses and the resident's need for an eye doctor but did not take appropriate action to address the issue. The resident had a prescription for new glasses in July 2022 but had not seen an eye doctor since then. The facility's policy on the exercise of rights states that residents have the right to a dignified existence with access to necessary services. However, the facility did not ensure that the resident had access to vision care, which would have enhanced his sense of well-being. This failure was confirmed through interviews with the resident and the administrative nurse, as well as a review of the resident's medical records and care plan.
Failure to Use Foot Pedals While Transporting Resident in Wheelchair
Penalty
Summary
The facility failed to safely transport Resident 12 in his wheelchair by not utilizing foot pedals while propelling him. Resident 12, diagnosed with Alzheimer's disease and exhibiting severe cognitive impairment, required substantial to maximal assistance for mobility. Observations on multiple occasions revealed that Certified Nurse Aides (CNAs) propelled the resident in his wheelchair without foot pedals, causing his shoed feet to skim the floor. Both CNAs acknowledged that the foot pedals were available in the resident's room but were not used because the resident sometimes propelled himself, and the pedals could be a tripping hazard. Interviews with staff, including a Licensed Nurse and an Administrative Nurse, confirmed that it was the facility's expectation to use foot pedals while propelling residents in wheelchairs. The facility's policy on Activities of Daily Living, revised in September 2023, stated that residents unable to carry out activities of daily living should receive necessary care and services to maintain mobility. Despite this policy, the facility failed to ensure the safe transport of Resident 12, leading to a deficiency in providing adequate supervision to prevent accidents.
Failure to Timely Monitor Adverse Effects of Antipsychotic Medications
Penalty
Summary
The facility failed to ensure timely monitoring for adverse effects of antipsychotic medications for three residents. Resident 18, who had diagnoses including chronic embolism, edema, and paranoid personality, was prescribed Seroquel. However, the initial Abnormal Involuntary Movement Scale (AIMS) test was not conducted until 14 days after the medication was started, contrary to the facility's policy of conducting the test at the start of therapy. This delay in monitoring could have missed early signs of adverse effects from the medication. Resident 35, diagnosed with vascular dementia and major depressive disorder, was also prescribed quetiapine fumarate. The initial AIMS test for this resident was conducted seven months after the medication was started, significantly later than the facility's policy of conducting the test at the start of therapy and every six months thereafter. This lack of timely monitoring could have resulted in unrecognized adverse effects from the medication. Resident 34, diagnosed with dementia, was prescribed Seroquel for agitation. The AIMS test for this resident was conducted 21 days after the medication was started, which was not in line with the facility's expectation of completing the test within the first week of administering a new antipsychotic medication. The facility also lacked a policy for the timely completion of AIMS assessments, further contributing to the deficiency in monitoring for adverse effects of antipsychotic medications.
Improper Disposal of Fentanyl Patch
Penalty
Summary
The facility failed to properly dispose of a used Fentanyl patch after it was removed from the hip of a resident. On 04/16/24 at 10:51 AM, a Licensed Nurse (LN) folded the used patch with the sticky side together and threw it into the trash can in the resident's room. The LN stated she was unaware that the patches needed to be disposed of in a special manner. The Administrative Nurse confirmed that the patches should not be disposed of in a resident's trash can and should be disposed of per facility policy. The facility policy, effective 04/01/22, required used transdermal systems to be disposed of in a trash receptacle on the medication cart or made unusable by mixing with an undesirable substance or using a commercially available disposal kit.
Failure to Provide Sanitary Dressing Change for Resident's Venous Ulcers
Penalty
Summary
The facility failed to monitor and provide a sanitary dressing change for a resident's venous ulcers. The resident, who had a history of chronic embolism, edema, and a severely impaired cognitive status, was assessed at risk for skin breakdown. Despite being instructed by the physician to administer antibiotics and perform specific wound care, the facility's staff did not follow proper sanitary procedures. On one occasion, a licensed nurse placed dressing supplies directly on the floor without a sanitary barrier, contrary to the facility's wound care guidelines. This unsanitary practice was observed during a dressing change for the resident's left lower extremity, which had cellulitis, blisters, and weeping wounds. The resident's care plan lacked timely instructions for wound care, and there was a delay in updating the care plan to include wound care instructions. The physician had instructed specific wound care procedures, including the use of an Unna boot and recording wound measurements, drainage, and signs of infection. However, the facility's staff did not adhere to these instructions, as evidenced by the unsanitary dressing change observed. Interviews with the licensed nurse and administrative nurse confirmed that the dressing supplies should have been placed on a sanitary barrier, not directly on the floor, indicating a failure to follow proper infection prevention and control protocols.
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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 Pratt
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grand Plains Skilled Nursing By Americare | 0.6 mi | ★★★★★ | 3 | 0 |
| Hilltop Manor Nursing Center | 16.3 mi | ★★★★★ | 22 | 1 |
| Haviland Operator, Llc | 20.9 mi | ★★★★★ | 5 | 0 |
| Leisure Homestead At Stafford | 22 mi | ★★★★★ | 32 | 0 |
| The Wheatlands Health Care Center | 33 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.