Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Russell Regional Hospital Ltcu during CMS and state inspections, most recent first.
Incomplete PBJ Staffing Submission: The facility failed to submit complete and accurate PBJ staffing data to CMS. CMS reports showed no RN hours for multiple days in one quarter and no data submitted for several other quarters, even though record review showed an LPN/RN was on duty daily, including weekends. Staff stated the coordinator was responsible for submitting the PBJ using the internal clocking system and agency time reports, and no PBJ policy was provided.
QAA Committee Lacked Medical Director Attendance: The facility failed to ensure the Medical Director attended QAA meetings at least quarterly. Attendance records showed monthly QAA meetings over a year, but there was no evidence the Medical Director attended any of them. Staff interviews confirmed he had not attended the meetings, while the QAPI plan required quarterly QAPI meetings and identified the Quality Manager as responsible for organizing them.
The facility failed to implement a Legionella water management program. Maintenance staff stated the prior supervisor was no longer at the facility and that records for water testing, completion of the water management process, and test results could not be located. Administrative staff later verified the facility could not find the Legionella policy or the maintenance log documenting the program, and no policy for Legionella disease prevention and maintenance was provided.
Unqualified Infection Preventionist Assigned: The facility failed to ensure the staff member responsible for the infection prevention and control program had completed the required specialized training/certification. An Administrative Nurse stated she had assumed the IP role after the prior IP resigned, but she was not certified. The facility’s policy required the IP to assist the DON with surveillance, records, policies, and ongoing QA for infection control.
A resident with dementia, Alzheimer’s disease, depression, anxiety, and normal pressure hydrocephalus received Seroquel 50 mg TID, but the EMR lacked a documented physician rationale, including failed nonpharmacological interventions and a risk-versus-benefits statement. The MDS and CAA documented severe cognitive impairment and antipsychotic use, and an admin nurse later verified the diagnosis tied to the medication was inappropriate.
Missing Background Checks for Three CNAs: The facility failed to complete background checks for three CNAs who had been employed for months to years. One CNA was scheduled as a bath aide and assisted a resident with a shower, while staff later confirmed they could not find background checks in the employees' files. The facility policy stated that all applicants for employment must have screening checks completed.
Failure to Implement Individualized Fall Prevention Interventions: A resident with dementia, impaired decision-making, and dependence on staff for mobility and ADLs had a fall with injury when a CNA multitasked while walking her with a walker. The care plan lacked resident-centered fall prevention interventions, and the EMR did not contain a documented fall risk assessment before or after the incident. The resident sustained multiple skin tears, and staff later acknowledged the resident was a fall risk and needed updated fall interventions.
Failure to assess safe use of an electric lift recliner and prevent a resident fall: one resident with DM, diabetic neuropathy, severe cognitive impairment, weakness, and repeated falls had no documented safety assessment for the recliner before sliding out of it when it was fully elevated. Another resident with dementia, impaired decision-making, and ADL dependence had no documented fall risk assessment and sustained multiple skin tears when a CNA multitasked while walking with the resident and the resident lost balance and fell into a nightstand.
A resident with DM, HTN, and heart failure had repeated blood glucose readings below the physician’s ordered notification threshold, but the EMR lacked documentation that the physician was notified. The resident also received lisinopril on multiple occasions when BP readings were outside the ordered hold parameters, and staff interviews confirmed the orders should have been followed.
A resident’s Novolog flex pen on the treatment cart was observed with an opened date but was not properly managed when it expired after 28 days. An LPN verified that insulin flex pens should be labeled with the date opened and expired pens discarded. The facility policy stated that medication inspections ensure medications are stored properly and outdated medications are removed and replaced.
Failure to Investigate and Report Injury of Unknown Origin: A resident with PVD, HTN, GERD, moderately impaired cognition, and dependence for most ADLs developed an unexplained dark purple bruise/discoloration on the forearm. Nursing notes showed the injury faded over several days, but the record lacked any investigative notes, witness statements, or root cause documentation. An Administrative Nurse confirmed staff did not investigate or gather statements, despite policy requiring immediate reporting and investigation of injuries of unknown source.
A resident with dementia, severely impaired cognition, and swallowing issues showed drooling and a blank stare during supper, but the nurse did not complete a physical assessment after the choking episode. The nurse attempted to give more food and drink, left the resident while the CNA removed food from the resident’s mouth, and the EMR lacked documentation of a post-incident assessment or follow-up.
Incomplete PBJ Staffing Submission
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS through the Payroll Based Journal (PBJ) based on payroll and other verifiable and auditable data. The facility had a census of 19 residents. CMS PBJ reports showed no RN hours for 31 days in October 2024, 30 days in November 2024, and 31 days in December 2024 for FY 2025 Q1, and the facility failed to submit PBJ data for FY 2025 Q2, FY 2025 Q3, and FY 2024 Q4. Record review for the dates in question showed that a licensed nurse was on duty 24 hours a day, seven days a week, and an RN was on duty at least 8 hours per day, seven days a week, including weekends. On interview, Administrative Staff A stated he did not realize there was still a problem with PBJ because he thought it had been fixed, and Administrative Nurse D stated the coordinator was responsible for sending in the PBJ information using the internal clocking system and agency staff time reports. A PBJ policy was not provided upon request.
QAA Committee Lacked Medical Director Attendance
Penalty
Summary
The facility failed to ensure the Medical Director attended the Quality Assessment and Assurance (QAA) Committee meetings at least quarterly as required. The facility provided QAA committee attendance dates from 09/25/24 through 08/28/25, but the documentation did not show that the Medical Director attended any of those meetings. During interviews, Administrative Staff B stated on 09/16/25 that since she took over the QAA position in March, the Medical Director had not attended any of the meetings and that she organized and ran all of them. Administrative Staff A stated on 09/16/25 that the Medical Director did not attend every meeting but thought he had attended at least quarterly, then later verified on 09/17/25 that the Medical Director had not attended any QAA meetings for the last year. The facility's QAPI plan, dated 09/13/23, stated that QAPI meetings would be held at least quarterly and that the Quality Manager would be responsible for organizing them and collecting quality data and reports from each department and service.
Failure to Maintain Legionella Water Management Documentation
Penalty
Summary
The facility failed to implement a water management program for Legionella disease. The census was 19 residents and the sample included eight residents. During observation, record review, and interview, Maintenance Staff U stated on 09/16/25 at 09:20 AM that the prior maintenance supervisor was no longer with the facility and that the facility was unable to locate or retrieve information regarding Legionella water testing or the water management process, including whether or when it had been completed and the testing results. Maintenance Staff U also stated that the information material was available when the facility implemented a policy for water management, but documentation showing the process was completed was lacking. Later that day at 02:00 PM, Administrative Staff A verified that the facility could not find the Legionella policy or the book in which maintenance staff had documented the water management for Legionella, and the facility failed to provide a policy for Legionella disease prevention and maintenance upon request.
Unqualified Infection Preventionist Assigned
Penalty
Summary
The facility failed to ensure that the staff member designated as the Infection Preventionist, who was responsible for the Infection Prevention and Control Program, completed the specialized training in infection prevention and control. The facility had a census of 19 residents. During record review and interview on 09/15/25 at 04:30 PM, Administrative Nurse D stated she was responsible for the Infection Prevention and Control Program but did not have certification as an Infection Preventionist. She stated the facility had an Infection Preventionist a few months earlier, but that person resigned, and the facility had been unable to fill the position, so she assumed the role without certification. The facility’s Infection Preventionist policy dated 08/2024 stated the Infection Control Preventionist would assist the DON in controlling the spread of infection, maintain surveillance of resident and employee infections, comply with regulations and licensing standards, develop and maintain policies and procedures, maintain accurate records and statistical data, perform continual needs analysis and assessment, and develop and implement an ongoing quality assurance program under the supervision of the DON.
Lack of documented rationale for antipsychotic use
Penalty
Summary
The facility failed to ensure an appropriate indication, or a documented physician rationale, for Resident 7’s continued use of Seroquel, an antipsychotic medication. Resident 7’s record showed diagnoses of dementia, Alzheimer’s disease, major depressive disorder, anxiety, and normal pressure hydrocephalus, and the Quarterly MDS documented severely impaired cognition, need for staff assistance with most ADLs, inattentiveness, disorganized thinking, and receipt of antipsychotic medication during the observation period. The Psychotropic Drug Use CAA also recorded antipsychotic use along with dementia, delirium, and depression diagnoses. Resident 7’s care plan identified risk for increased behaviors and adverse effects related to dementia, a history of psychosis with delusional disorder, normal pressure hydrocephalus, restlessness, agitation, depression, anxiety, and use of medication with black box warnings, and it directed staff to consult the provider and pharmacist regarding psychotropic use and dose reductions. The physician’s order directed Seroquel 50 mg three times daily for normal pressure hydrocephalus, but the EMR lacked a documented physician rationale, including unsuccessful nonpharmacological symptom management attempts and a risk-versus-benefits statement for continued use. Observation showed the resident receiving the morning dose of Seroquel, and an administrative nurse later verified the medication was being given for normal pressure hydrocephalus and stated that diagnosis was inappropriate for the medication.
Missing Background Checks for Three CNAs
Penalty
Summary
The facility failed to provide background checks for three CNAs who had been employed since 2023 and 2024. Review of the background check records showed no completed background check for CNA P, hired on 03/07/23, CNA Q, hired on 08/08/23, and CNA MM, hired on 02/13/24. The Nursing Schedule dated 09/15/25 documented CNA MM as scheduled as a bath aide for the Long-Term Care Unit, and on 09/15/25 at 11:06 AM, CNA MM assisted a resident with a shower. On 09/15/25 at 01:26 PM, Administrative Staff A stated he checked the CNAs' files and could not find that a background check had been completed before the CNAs were hired. On 09/16/25 at 01:45 PM, Administrative Staff C stated that applicants were sent a letter of intent to hire and, if accepted, were asked to provide information for a background check, but she was unable to find background checks for the three CNAs. Administrative Staff C also stated the facility decided to run background checks for all staff to make sure no others were missed. On 09/16/25 at 02:00 PM, Administrative Nurse D stated all staff should have a background check completed before hire and had no concerns with the three CNAs who had not had a background check. The facility's Suspected Abuse, Neglect, and Exploitation policy dated 09/13/23 stated that all applicants for employment shall, at a minimum, have screening checks conducted.
Failure to Implement Individualized Fall Prevention Interventions
Penalty
Summary
The facility failed to implement individualized, person-centered interventions to prevent falls for one resident with dementia, anxiety, major depressive disorder, hypertension, memory impairment, impaired decision-making, dependence on staff for toileting, dressing, hygiene, mobility, transfers, and ambulation, and a history of one fall with injury. The resident’s care plan included assistance to and from activities, frequent toileting, and walking to dine with a walker and wheelchair follow, but it lacked resident-centered interventions to prevent further falls. The electronic medical record also lacked documentation of a Fall Risk Assessment completed before or after the resident’s fall. The resident’s incident report documented that a CNA walked the resident with a walker out of the bathroom, then turned to toss a laundry bag to the floor while the resident was ambulating. The resident lost balance and began to fall, and the CNA lowered her to the floor as she hit the nightstand. The resident sustained three skin tears to the right elbow and one skin tear to the left elbow, which were cleansed, steri-strips applied, and covered with dressings. Staff interviews later confirmed the resident was a fall risk, that two staff members were with her when she ambulated, and that the care plan should be updated with fall interventions to prevent further falls.
Failure to Assess Safe Recliner Use and Prevent a Resident Fall
Penalty
Summary
The facility failed to assess a resident for safe use of an electric lift recliner. The resident had diagnoses including DM, diabetic neuropathy, major depressive disorder, weakness, and repeated falls. The admission MDS recorded a BIMS score of 7, indicating severe cognitive impairment, and documented that the resident required substantial to maximal staff assistance with chair-to-bed transfers, sit-to-stand transfers, and had a history of falls before admission, including one that resulted in a fracture. The fall care plan identified the resident as at risk for falls due to poor gait balance, deconditioning, psychoactive drug use, and prior falls, and directed staff to encourage use of the call light and provide prompt response to requests for assistance. The resident’s record lacked evidence that the facility assessed safe use of the electric lift recliner. The resident later had an unwitnessed fall from the recliner when it was elevated all the way up, and slid out of the chair and landed on the floor. The nurse’s note documented that two staff members used a manual sit-to-stand lift to transfer the resident from the floor back to the recliner, and no complaints of pain or discomfort were noted during the transfer. Administrative nursing staff verified that the resident had the electric lift recliner since admission and that no safety assessment for use of the chair had been completed by nursing or physical therapy. The facility also failed to prevent a fall for another resident that resulted in skin tears. That resident had diagnoses of dementia, anxiety, major depressive disorder, and hypertension, with the quarterly MDS documenting memory problems, moderately impaired decision-making, dependence on staff for multiple activities of daily living, substantial assistance needs for mobility, transfers, and ambulation, and a history of one fall with injury. The care plan directed staff to assist the resident with activities, toilet frequently, and walk to dine with a walker and wheelchair follow, but lacked resident-centered interventions to prevent further falls. The EMR lacked documentation of a fall risk assessment before or after the fall. During the incident, a CNA walked the resident with a walker out of the bathroom, turned to toss a laundry bag while ambulating, and the resident lost balance and fell into the nightstand, sustaining three skin tears to the right elbow and one skin tear to the left elbow.
Failure to Follow Physician Parameters for Blood Sugar and Blood Pressure
Penalty
Summary
The facility failed to notify the physician when a resident’s blood sugar was outside the ordered parameters and failed to hold the resident’s lisinopril when her blood pressure was outside the physician’s hold parameters. The resident had diagnoses of diabetes mellitus, hypertension, and heart failure, and her care plan directed staff to obtain blood glucose checks as ordered, report abnormal values, and administer insulin per order, as well as to obtain blood pressure readings, notify the physician of abnormal values promptly, and follow the physician’s instructions for cardiac concerns. The physician ordered staff to notify him if the resident’s blood sugar was lower than 80 mg/dl and to hold lisinopril if systolic blood pressure was less than 100 mmHg or diastolic blood pressure was less than 60 mmHg. The MAR documented multiple instances when lisinopril was administered despite blood pressure readings below the ordered parameters, including readings with low diastolic values and one reading with both systolic and diastolic values below parameters. The MAR also documented multiple low blood sugar readings, including values of 54, 63, 59, 62, 55, and 45 mg/dl, and the EMR lacked physician notification related to the out-of-parameter blood sugars and blood pressure readings. Staff interviews confirmed awareness that the physician should have been contacted for the low blood sugars and that the blood pressure medication should have been held when out of parameters.
Improper Labeling and Expired Insulin Flex Pen
Penalty
Summary
The facility failed to label Resident 1’s insulin flex pens when they were initially opened for use and when they expired. On observation of the treatment cart, Resident 1’s Novolog flex pen was found with an opened date of [DATE], and the insulin had expired on [DATE] because it is good for 28 days. During interview, the License Nurse verified that nurses should label and date insulin flex pens with the date opened and discard expired insulin flex pens. The facility’s Labeling of Medications policy stated that medication inspections are done to ensure medications are stored under proper conditions and that all outdated medications are removed and replaced with usable medications.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure staff investigated a potential allegation of abuse involving an injury of unknown origin and failed to report the incident immediately to the administrator for investigation. R2 had diagnoses of PVD, HTN, and GERD, a BIMS score of 11 indicating moderately impaired cognition, dependence on staff for most ADLs, substantial assistance needed for transfers, wheelchair use for mobility, and a Braden score of 18 indicating risk for pressure ulcers. The care plan directed two staff for all transfers, use of a wheelchair, the bed in the lowest position while occupied, monitoring for pain, reality orientation when confused, and observation for injury or entrapment related to half rails. Nursing notes documented a dark purple discoloration and bruising to R2's right forearm on 05/11/25, with the resident unable to explain how it occurred and denying pain or discomfort. Subsequent notes described the bruising as fading over the next several days, and the record contained no investigative documentation, including witness statements or root cause analysis. Administrative Nurse D stated the facility did not investigate or gather witness statements and was unaware of how the injury occurred, despite the facility policy requiring unknown-source injuries to be reported immediately and investigated.
Failure to Assess Resident After Choking Signs During Meal
Penalty
Summary
The facility failed to complete a physical assessment after a resident showed signs of choking during the supper meal. The resident had diagnoses including dementia, anxiety, major depressive disorder, and hypertension, and the Quarterly MDS documented severely impaired cognition, setup assistance for eating and oral hygiene, no functional limitation in range of motion, and a mechanically altered diet. The care plan directed staff to monitor food and fluid intake, offer and encourage fluids and snacks, provide direct supervision at mealtimes, and noted swallowing issues with a drinkable pureed diet; an update later directed a regular diet with liquidized texture and nectar thick, mildly thick liquids. During the meal incident, a CNA observed the resident drooling and reported it to the nurse. The nurse looked at the resident, asked her to take a drink of milk, and then put food into the resident’s mouth. The CNA documented that the resident continued to drool and had a blank stare, grunted when questioned, and was unable to spit out the food. The CNA then inserted her finger into the resident’s mouth multiple times to remove the food, while the nurse stood by and did not assist. The facility’s investigation also documented that the nurse attempted to give more to drink when the resident was already drooling, wiped the resident’s mouth, left the resident to clean tables, and did not assist when the CNA removed multiple chunks of food from the resident’s mouth. The resident’s EMR lacked documentation of a physical assessment after the incident or of continued concern. Administrative staff stated the nurse did not report the incident, and the administrative nurse stated there were no assessments of the resident’s lungs completed by the nurse, except for blood pressure and pulse, and that the incident and follow-up were not documented in the EMR. The facility policy required staff to observe, record, and report condition changes, notify the physician and responsible party, and monitor the resident frequently until stable after changes in physical or mental function.
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Illustrative
What surveyors actually found near you
We read the 25 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Russell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wheatland Nursing & Rehabilitation Center | 0.2 mi | ★★★★★ | 0 | 0 |
| Wilson Care And Rehab | 21.1 mi | ★★★★★ | 19 | 0 |
| Via Christi Village Hays Ks Llc | 23.6 mi | ★★★★★ | 6 | 0 |
| Good Samaritan Society - Hays | 25.5 mi | ★★★★★ | 0 | 0 |
| Redbud Village | 33.3 mi | — | 2 | 0 |
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