Above average — CMS composite of the measures below.
The next survey window likely opens 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 Sabetha Manor during CMS and state inspections, most recent first.
Failure to employ a qualified Dietary Manager: A dietary staff member identified herself as the Dietary Manager but stated she was not certified. She was observed preparing breakfast and later preparing a pureed meal for a resident. Admin staff reported the facility had checked on certification, but the staff member had not been enrolled in the course.
Unsanitary Food Handling and Kitchen Hygiene: Dietary staff prepared and served meals with hair not fully contained in hair restraints, used the same gloves after touching a face mask and multiple kitchen surfaces, and handled food without changing gloves between tasks. Kitchen fans above the prep area also had visible brown and gray debris on the blade covers, and staff later verified that hair should be contained, fans should be clean, and gloves should be changed appropriately.
Expired stock medications were found in the medication room, including opened bottles of Folic Acid and Vitamin E with past expiration dates. A CMA verified the dates, while an LPN stated CMAs tracked expired meds on the cart and nursing administration reviewed stock meds. The consultant pharmacist was involved in checking for expired medications, and the facility policy required routine inspection of the pharmacy and medication rooms for outdated medications.
A resident with dementia was found with bruising of unknown origin, which was not reported to the State Agency as required. The facility's investigation attributed the bruising to pressure from a shower chair and the resident's fragile skin, but failed to adhere to policy mandating reporting of such incidents. Staff interviews revealed a misunderstanding of reporting requirements, placing the resident at risk for unresolved abuse.
The facility failed to provide RN coverage for eight consecutive hours a day, seven days a week, and did not employ a full-time DON. A review of the nursing schedule for August, September, and October 2023 revealed multiple dates without RN coverage. Administrative Staff A confirmed the absence of a current DON and lack of verifiable documentation for RN coverage on specific dates, violating the facility's policy and placing residents at risk for decreased quality of care.
The facility failed to employ a full-time certified dietary manager for 25 residents, placing them at risk for inadequate nutrition. Dietary Staff BB, who was preparing meals, was not certified and was still completing the dietary manager class. Administrative Staff A confirmed the lack of certification, contrary to the facility's policy.
The facility failed to store, prepare, distribute, and serve food safely, with expired and improperly stored food items found in the kitchen. Additionally, several maintenance and cleanliness issues were observed, including peeling paint, rusted counter legs, and missing cabinet layers. These deficiencies placed 25 residents at risk for foodborne illness.
The facility failed to submit complete and accurate staffing information through PBJ, placing residents at risk for inadequate nurse staffing. CMS reports indicated missing licensed nurse coverage on multiple dates, but facility records showed 24/7 coverage. Consultant Nurse GG confirmed correct reporting, but discrepancies remained.
The facility failed to have the required members, including a Director of Nursing (DON) and an Infection Preventionist, participate in QAPI meetings at least quarterly. The absence of these key roles in the QAPI committee was confirmed by Administrative Staff A and documented in the facility's QAPI policy. This deficiency placed the 25 residents at risk for decreased quality of care.
The facility failed to employ a designated Infection Preventionist (IP) responsible for the Infection Prevention and Control Program (IPCP). Administrative Staff A and Nurse Consultant GG confirmed the absence of an IP, which was required by the facility's policy. This oversight placed residents at increased risk for infections.
The facility failed to check the food temperatures of pureed foods and regular breakfast food items before serving, placing residents at risk for foodborne illness and impaired palatability. The Dietary Manager admitted to not routinely checking food temperatures, and the Food Temp Sheets lacked recorded temperatures for breakfast and pureed food items.
The facility failed to provide timely written notification to a resident or her representative regarding a facility-initiated transfer to the hospital and did not notify the LTCO. The resident, who had COPD and required continuous oxygen, was transferred without the required written notice, and the social service staff was unaware of their responsibility due to a lack of training.
The facility failed to provide a resident or his representative with written information regarding the bed hold policy when the resident, who had COPD and required continuous oxygen, was transferred to the hospital. This oversight was confirmed through staff interviews and a review of the resident's medical record.
Failure to Employ a Qualified Dietary Manager
Penalty
Summary
The facility failed to employ a full-time Certified Dietary Manager for residents who received meals from the kitchen. During the initial kitchen tour on 01/20/26 at 07:30 AM, Dietary Staff BB was observed preparing breakfast and identified herself as the Dietary Manager, but stated she was not certified. On 01/21/26 at 11:45 AM, DS BB was observed chopping lettuce and preparing a pureed meal for one resident. Later that day at 12:57 PM, Administrative Staff A stated the facility had checked with an institute about DS BB becoming certified, but she had not been enrolled in the course. The facility’s Dietary Service-Staffing policy stated that the facility employs sufficient staff with the appropriate competencies and skill sets to carry out Food and Nutrition Services and will employ a qualified dietitian or other clinically qualified nutrition professional on a full-time, part-time, or consultant basis.
Unsanitary Food Handling and Kitchen Hygiene
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner for residents receiving meals from the kitchen. During an initial kitchen tour, a dietary staff member was preparing breakfast while wearing a hair net with approximately six inches of brown hair hanging out on each side of the face. The following day, the same dietary staff member assisted with lunch preparation, including chopping lettuce and pureeing entrees, without hair being fully contained in a hairnet on both sides of the face. During lunch preparation, another dietary staff member put on clean gloves, touched a facial mask to adjust it with the palm of the hands, and then retrieved shredded cheese to top Shepard's Pie without changing gloves. The staff member also touched the refrigerator handle, removed the cheese container, opened the oven door, pulled the pan from the oven with a potholder, and then reached into the shredded cheese container to spread cheese on the main dish. The same staff member used unclean gloves to obtain baked rolls from a pan and place them on residents' plates during plating. The kitchen also had two wall-mounted fans above the ice machine and food prep area, stove, and grill; the fan blowing toward the meal prep area had brown and gray debris on the blade covers. A dietary staff member and an administrative staff member later verified that hair should be contained in the hair covering, fans should be clean and free of debris, and gloves should have been changed between tasks and after touching the face mask.
Expired Medications Found in Medication Storage Areas
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles because expired medications were found in the facility’s medication storage areas. During an observation of the medication room, an opened bottle of Folic Acid 400 mcg with an expiration date of 02/25 and Vitamin E 180 mg with an expiration date of 09/25 were found among stock medications in the medication room with CMA S present, and CMA S verified the expired dates on both bottles. LN H stated that CMAs kept track of expired medications on the medication cart and that stock medications were reviewed for expiration dates by nursing administration. Consultant GG later stated that the consultant pharmacist helped check for expired medications and reported that the medication room should be checked weekly. The facility’s Medication Storage policy stated that medications were to be stored according to manufacturer recommendations and that the pharmacy and medication rooms were routinely inspected for discontinued, outdated, defective, or deteriorated medications.
Failure to Report Allegation of Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of abuse and an injury of unknown origin involving a resident, identified as R1, to the State Agency (SA) as required. R1, who had a diagnosis of dementia and was dependent on staff for activities of daily living, was found to have bruising on her left arm of unknown origin. The bruising was reported by R1's hospice nurse, who noted two large bruises and several smaller ones. Despite the bruising being of unknown origin, the facility did not report the incident to the SA, which is a requirement when the cause of an injury cannot be determined. The investigation into the bruising revealed that a Certified Nurse Aide (CNA) had mentioned that another CNA could be rough when handling residents, although this was later retracted as a statement made in frustration. The investigation concluded that the bruising was likely due to pressure from leaning on a hard plastic shower chair, combined with R1's fragile skin and use of blood thinners. Despite this conclusion, the facility's policy required that any allegation of abuse or injury of unknown origin be reported to the SA within a specified timeframe, which was not done in this case. Interviews with facility staff indicated a lack of understanding or adherence to the reporting requirements. Administrative staff stated that they only reported to the SA if an investigation found evidence of abuse or neglect, which contradicts the facility's policy that mandates reporting of any allegations or injuries of unknown origin. This oversight placed R1 at risk for unresolved and ongoing abuse, as the proper authorities were not notified to conduct an independent investigation.
Failure to Provide RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week, and did not employ a full-time Director of Nursing (DON). This deficiency was observed through a review of the nursing schedule for August, September, and October 2023, which revealed multiple dates where RN coverage was not maintained. Additionally, during an interview on March 13, 2024, Administrative Staff A confirmed the absence of a current DON and the lack of verifiable documentation for RN coverage on specific dates. The facility's policy, revised in February 2023, required RN services for at least eight consecutive hours per day, seven days per week, and a full-time DON, which the facility failed to comply with, placing residents at risk for decreased quality of care.
Failure to Employ Certified Dietary Manager
Penalty
Summary
The facility failed to employ a full-time certified dietary manager for the 25 residents who resided in the facility and received meals from the facility kitchen. On 03/13/24 at 11:00 AM, the noon meal consisted of grilled sausage cuts, German potato salad, sauerkraut with bacon, and cookies. At 11:30 AM, observation revealed Dietary Staff BB in the kitchen preparing the noon meal. At 11:35 AM, Dietary Staff BB verified she was not a certified dietary manager and stated she was on the last section of the dietary manager class. On 03/13/24 at 09:51 AM, Administrative Staff A confirmed that Dietary Staff BB did not have a dietary manager certification. The facility's Dietary Services-Staffing Policy, revised February 2023, documented the facility would employ a qualified dietitian or other clinically qualified nutrition professional on a full-time, part-time, or consultant basis. This placed the residents at risk for inadequate nutrition.
Food Storage and Kitchen Cleanliness Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations revealed that the kitchen contained unlabeled, undated, and expired food items, including seven 4-ounce vanilla Mighty Shakes and several Ensure products with past expiration dates. Additionally, an unsealed package of yellow cheese slices was found in the refrigerator. These findings were verified by Social Service X, who discarded the expired items. The presence of expired and improperly stored food items placed the 25 residents at risk for foodborne illness. Further observations in the kitchen highlighted several maintenance and cleanliness issues. The mopboard around the kitchen had a black substance, and parts of it were coming away from the wall. The oven hood had peeling paint, and the cabinets had missing top layers of wood and exposed screws. The area underneath the ice machine was cluttered with plastic gowns and a cup lid, and the legs of the counter were rusted. The pipe under the dishwasher had numerous areas of brown substance, and a board above the sink had a missing top layer of wood. These issues were verified by the Dietary Manager, who acknowledged the kitchen's short-staffing problem and the need for maintenance. The facility's Dietary Cleaning Procedures Policy was not followed, leading to unsanitary conditions that could contribute to foodborne illnesses among residents.
Failure to Submit Accurate PBJ Data
Penalty
Summary
The facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required, which placed residents at risk for unidentified and ongoing inadequate nurse staffing. The PBJ report provided by CMS for Fiscal Year (FY) 2023 Quarter 4 and FY 2024 Quarters 1 indicated that the facility did not have licensed nurse coverage 24 hours a day, seven days a week on multiple (15) dates. However, a review of the facility's licensed nurse timeclock data for those dates revealed that a licensed nurse was on duty for 24 hours a day, seven days a week. On 03/20/24, an observation confirmed a registered nurse on duty in the facility. Consultant Nurse (CN) GG, who assisted with reporting data to CMS, stated that her documentation showed the information was reported correctly, and she was unsure why CMS records differed. The facility's Payroll-Based Journal Policy, revised in February 2023, documented that the facility would electronically submit timely and accurate direct care staffing information to CMS, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to CMS specifications.
Failure to Include Required Members in QAPI Meetings
Penalty
Summary
The facility failed to have the required members participate and attend Quality Assurance and Performance Improvement (QAPI) meetings at least quarterly. Specifically, the QAPI committee sign-in sheets for quarterly meetings lacked a Director of Nursing (DON) and an Infection Preventionist on multiple occasions, including 03/07/24, 01/23/24, 11/28/23, and 09/26/23. Administrative Staff A confirmed that the facility did not employ a full-time DON or an Infection Preventionist. The facility's undated QAPI policy documented that the Quality Assurance Committee should include these roles. This deficiency placed the 25 residents in the facility at risk for decreased quality of care.
Failure to Employ Designated Infection Preventionist
Penalty
Summary
The facility failed to ensure the employment of a designated Infection Preventionist (IP) responsible for the Infection Prevention and Control Program (IPCP). During the initial entrance conference, Administrative Staff A confirmed the absence of an IP. Additionally, Nurse Consultant GG, who had been tracking infections, verified that the facility did not have an onsite IP. This lack of a designated IP with the required certification was a significant oversight in the facility's infection control measures. The facility's undated policy on infection prevention documented the requirement to employ one or more qualified individuals responsible for implementing the IPCP. The policy also outlined the need for the IP to be qualified by education, training, and certification. The absence of a designated IP meant that the facility did not have a dedicated person to develop and implement an ongoing infection prevention and control program, oversee the antibiotic stewardship program, and ensure the annual review and revision of the IPCP. This failure placed the residents at increased risk for infections.
Failure to Check Food Temperatures
Penalty
Summary
The facility failed to check the food temperatures of pureed foods and regular breakfast food items before serving, which placed residents at risk for foodborne illness and impaired palatability. The Dietary Manager (DM) was observed preparing pureed meals without assessing the food temperatures. Specifically, pureed sausage, potatoes, and sauerkraut were all served at 120 degrees Fahrenheit, which is below the required 135 degrees Fahrenheit for hot foods. The DM admitted to not routinely checking food temperatures before serving and stated that breakfast food temperatures were not checked because the food was made to order. Additionally, the Food Temp Sheet for January, February, and March 2024 lacked recorded temperatures for breakfast and pureed food items. The facility's Record of Food Temperatures Policy, revised in February 2023, mandates that food temperatures be checked and recorded for all items prepared in the dietary department, with hot foods held at 135 degrees Fahrenheit or greater. However, the dietary staff failed to measure and record pureed and breakfast food item temperatures before serving them. This oversight was confirmed by the DM, who acknowledged that there was no column on the Food Temp Sheets to record pureed food temperatures. This failure to adhere to the policy placed residents at risk for foodborne illness and impaired palatability.
Failure to Provide Written Notification for Hospital Transfer
Penalty
Summary
The facility failed to provide timely written notification to Resident 14 or her representative regarding a facility-initiated transfer to the hospital. The resident, who had a diagnosis of chronic obstructive pulmonary disease (COPD) and required continuous oxygen, was transferred to the hospital without receiving the required written notice. Additionally, the facility did not notify the Office of the Long-Term Care Ombudsman (LTCO) of the transfer. The resident's medical record lacked evidence of the written notice, and the social service staff was unaware of their responsibility to provide such notification due to a lack of training. The facility's Emergency Transfer Notification Policy, revised in September 2018, mandates that residents and their representatives be notified verbally and in writing of emergency transfers, with documentation kept on file. However, this policy was not followed in the case of Resident 14. Social Service X confirmed that the transfer notice was not sent to the LTCO because it did not appear in the computer notification system. Licensed Nurse H also stated that social service staff was responsible for providing transfer information, but this was not done. This failure placed the resident and her representative at risk of making uninformed care choices.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide Resident 14 or his representative with written information regarding the facility's bed hold policy when the resident was transferred to the hospital. Resident 14, who had a diagnosis of chronic obstructive pulmonary disease (COPD) and required continuous oxygen, was admitted to the hospital on 02/05/2024. The resident's electronic medical record lacked evidence that the bed hold policy was provided to the resident or his representative at the time of transfer. This oversight was confirmed through interviews with the facility's social service staff and a licensed nurse, both of whom acknowledged that the bed hold policy should have been provided and documented. The facility's bed hold policy, revised in 11/2017, mandates that residents be made aware of the policy before and upon transfer to a hospital or when taking a therapeutic leave. In cases of emergency transfer, written notice must be provided within 24 hours. The policy also requires documentation of multiple attempts to reach the resident's representative if initial contact is unsuccessful. The failure to provide and document the bed hold policy placed Resident 14 at risk of not being permitted to return and resume residence in the nursing facility.
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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 Sabetha
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Apostolic Christian Home | 0.5 mi | ★★★★★ | 0 | 0 |
| Crestview Nursing & Residential Living | 14.2 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Seneca | 15 mi | ★★★★★ | 0 | 0 |
| Maple Heights Nursing & Rehabilitative Center | 15.7 mi | ★★★★★ | 1 | 0 |
| Falls City Care Center | 16 mi | ★★★★★ | 0 | 0 |
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