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 Southwind At Spearville during CMS and state inspections, most recent first.
Surveyors observed a dietary staff member plating meals while wearing the same pair of gloves to handle multiple food items, including ready-to-eat bread, and then touching her face and glasses before continuing to plate food without changing gloves or washing hands. The staff member reported she had been trained to serve in this manner and usually changed gloves several times during the process. These practices did not follow the facility’s hand hygiene policy, which requires handwashing in designated sinks, appropriate glove use when handling ready-to-eat food, and handwashing before distributing meals.
The facility used an admission packet containing an Arbitration Provision that did not inform residents or their representatives of their right to rescind the agreement within 30 days or that signing it was not a condition of admission. All residents had signed arbitration agreements, and staff reported that the provision in the packet was the only written information provided, with explanations given verbally at admission. Administrative staff and an administrative nurse indicated that the provision had been created by a previous company and possibly altered by current leadership, and they were not aware of the specific regulatory language required to be included in the arbitration agreement.
The facility used an admission packet arbitration provision for all 22 residents that did not inform residents or their representatives of their right to participate in selecting a neutral arbitrator or a mutually convenient venue. Administrative staff reported that the arbitration provision in the admission packet was the only written information provided and that they verbally explained it at admission, but they were not aware of the specific language required to be included. The arbitration language had been created under a previous company and may have been altered by the current board and administrator, yet it still lacked the required provisions, resulting in a deficiency related to the arbitration process.
A resident with atrial fibrillation and moderately impaired cognition had a care plan and physician order indicating DNR status, but the signed DNR document was missing from the EMR. During transfer from assisted living to LTC, the signed DNR did not carry over into the current chart, and an administrative nurse acknowledged there was no process in place to monitor or verify changes to advance directives, contrary to the facility’s Advance Directives policy requiring supporting documentation with a DNR order.
Surveyors found that the beauty shop was left unlocked and unattended while containing accessible hazardous items, including disinfectant sprays, shampoo, hair spray, curling irons, and an electric razor, with an unlocked cabinet holding additional disinfectant spray. This occurred despite the presence of cognitively impaired but independently mobile residents and despite a facility policy stating a commitment to eliminate and control hazardous chemicals and meet safety standards for hazards and potential hazards.
A resident with a colostomy and history of intestinal obstruction, who was cognitively intact, had a care plan and an ostomy policy requiring staff to monitor and document bowel sounds and bowel movements, including stool output, consistency, and color each shift. Staff did not document any bowel movement information in progress notes or tasks, and continence was left unrated due to the colostomy without recording amount, frequency, or consistency. A CNA was observed emptying the colostomy bag directly into the trash without measuring or documenting the stool and reported that staff do not monitor or report bowel movement details to nurses, while an RN confirmed that this resident’s bowel movements were not included in the usual bowel report process.
A resident with HTN and CHF, prescribed multiple antihypertensives and diuretics with specific BP and pulse parameters, did not receive valsartan, metoprolol, furosemide, or hydrochlorothiazide during a morning medication pass when a CMA obtained a BP in the low 100s systolic and 40s diastolic and reported it to an LN. The LN instructed the CMA to hold all ordered medications based on nursing judgment and did not notify the physician, despite orders outlining when to contact the provider. Documentation in the EMR and MAR reflected that the medications were held per nursing judgment, and no physician notification occurred.
The facility failed to submit complete and accurate staffing information through PBJ, resulting in multiple instances where Licensed Nursing Coverage was not reported as 24 hours a day, despite adequate hours being indicated in the nursing schedule and clocking sheets. An outside agency was responsible for the inaccurate data submission prior to November 1, 2023.
The facility failed to revise care plans for four residents related to falls and nebulizer use. Observations and interviews revealed that nebulizer equipment was not properly stored or cleaned, and care plans were not updated with new interventions after falls. The facility also failed to provide a policy regarding care plans when requested.
The facility failed to conduct a criminal background check for a CNA hired on 07/08/22. The Administrative Nurse confirmed the lack of background check information, which is required by the facility's policy on abuse prevention. This failure had the potential to negatively affect resident care.
The facility failed to ensure a safe environment for a resident with severe cognitive impairment and a history of falls. Despite multiple falls and a high fall risk score, the care plan lacked effective interventions, and staff did not adequately follow the facility's accident prevention policy. This resulted in repeated falls for the resident.
The facility failed to provide necessary respiratory care for two residents, including improper storage and cleaning of nebulizers, and lacked a policy on respiratory care. Observations and staff interviews confirmed these deficiencies.
The facility failed to complete annual performance reviews for three CNAs employed for over 12 months, as confirmed by administrative staff. This lapse was identified during a review of employee files, revealing a lack of performance evaluations to ensure adequate care and services for residents.
Improper Glove Use and Hand Hygiene During Meal Service
Penalty
Summary
Surveyors identified a deficiency in food preparation and service sanitation when observing the noon meal service for a census of 22 residents from the facility’s main kitchen. During the meal, a dietary staff member wearing gloves plated food by removing the lid from a roasting pan and using utensils to serve meat, potatoes, and spinach, then used the same gloved hand to pick up a roll and continued plating. While still wearing the same gloves, she touched her face and glasses and then resumed the plating process without removing the gloves or washing her hands. In a subsequent interview, the dietary staff member stated she had been trained to serve in that manner and typically changed her gloves about three times during the process. The facility’s written hand hygiene policy for food handlers requires that hands always be washed in designated handwashing sinks, that gloves be worn when serving residents on transmission-based precautions or when touching ready-to-eat food, and that staff perform handwashing prior to distributing meals.
Arbitration Agreement Lacked Required Rescission and Non-Condition of Admission Language
Penalty
Summary
The facility failed to ensure its arbitration agreement informed residents or their representatives of their right to rescind the agreement within 30 days of signing and that signing the agreement was not a condition of admission. With a census of 22 residents, all 22 had signed arbitration agreements, and there were no residents in active arbitration. Review of the admission packet showed that Exhibit E, titled Arbitration Provision, did not contain language notifying residents or representatives of the 30-day rescission right or that the arbitration agreement was optional and not required for admission. During interviews, an administrative staff member stated that the Arbitration Provision in the admission packet was the only information provided about the agreement and that she verbally explained it to new admissions when they signed, but there was no indication that the required language was included in writing. Another administrative nurse reported that the previous company had written the Arbitration Provision and that the current board and administrator might have modified it, and she was not aware of the specific language required to be included. A separate administrative staff member also stated they followed whatever the admission agreement said about the Arbitration Provision and acknowledged not being aware of the required elements of the provision. These findings demonstrate that the facility’s written arbitration documents, as provided to all residents at admission, lacked the federally required notifications regarding the right to rescind within 30 days and the non-mandatory nature of signing the arbitration agreement for admission, and that key administrative personnel were unaware of these specific regulatory requirements.
Deficient Arbitration Agreement Lacking Neutral Arbitrator and Venue Provisions
Penalty
Summary
The facility failed to ensure its arbitration agreement provided for the selection of a neutral arbitrator agreed upon by both parties and for the selection of a venue convenient to both parties. At the time of survey, the facility had a census of 22 residents, all of whom had signed the arbitration agreement, and there were no residents in active arbitration. Record review of the admission packet, specifically Exhibit E Arbitration Provision, showed it did not notify residents or their representatives of their right to participate in selecting a neutral arbitrator or a mutually convenient venue. During interviews, an administrative staff member stated that the Arbitration Provision in the admission packet was the only information provided about the agreement and that she verbally explained it to new admissions when they signed it. Another administrative nurse reported that the previous company that operated the facility had written the Arbitration Provision and that the current board and administrator might have modified it, and she was not aware of the specific language required in the provision. A further administrative staff member stated the facility followed whatever was written in the admission agreement regarding arbitration and acknowledged not being aware of the required elements for the Arbitration Provision. These combined actions and inactions—using an admission arbitration form that lacked required language about neutral arbitrator and venue selection, having all residents sign this form, and administrative staff’s lack of awareness of the required arbitration language—led to the identified deficiency.
Failure to Maintain Signed DNR Documentation in Clinical Record
Penalty
Summary
The facility failed to ensure that a resident’s documented Do Not Resuscitate (DNR) status was supported by a signed DNR document in the clinical record. The resident had a diagnosis of atrial fibrillation and an admission MDS showing a BIMS score of 12, indicating moderately impaired cognition. Her care plan documented that she chose to be a DNR and stated that the DNR order would be part of the medical record and reviewed with the care plan. The EMR also contained a physician’s order for a DNR. However, the EMR lacked evidence of the actual signed DNR document that was required to accompany the physician’s order. During the survey, the resident was observed in the dining room visiting with another resident. Administrative Nurse D reported that during the resident’s transfer from assisted living to long-term care, the signed DNR did not transfer into the current chart. Administrative Nurse D also stated that the facility did not have a process or system in place to monitor or verify changes for advance directives. The facility’s undated Advance Directives policy stated that a physician’s DNR order would be accompanied by supporting documentation in the resident’s clinical record, but this supporting documentation was not present for this resident.
Unlocked Beauty Shop With Accessible Chemicals and Heating Devices
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment by leaving the beauty shop, which contained heating devices and chemicals, unlocked and unattended. The facility had a census of 22 residents, including three residents who were cognitively impaired but independently mobile. On 01/27/26 at 10:06 AM, surveyor observation showed the beauty shop door unlocked and open with two cans of Clippercide spray (liquid disinfectant chemical), shampoo, hair spray, two curling irons, and an electric razor on the counter, and an unlocked cabinet containing a can of Lysol spray disinfectant, with no staff present in the room. On 01/28/26 at 02:09 PM, Administrative Staff D stated she expected the beauty shop to be closed and locked when no one was in it. The facility’s undated “Control of Hazardous Chemicals” policy stated the facility is committed to eliminating and controlling hazards that could cause injury or illness to elders and to meeting safety standards where there are specific rules about hazards or potential hazards in the facility. These observations and statements show that hazardous chemicals and heating devices were accessible in an unsecured area despite the presence of cognitively impaired but mobile residents and despite the facility’s stated policy on controlling hazardous chemicals.
Failure to Monitor and Document Colostomy Output
Penalty
Summary
The deficiency involves the facility’s failure to monitor and document bowel movements for a resident with a colostomy as required by the care plan and facility policy. The resident’s EMR documented diagnoses of colostomy and intestinal obstruction, and the admission MDS showed intact cognition with a BIMS score of 15. The resident’s care plan, initiated for dehydration or potential fluid deficit related to diuretic use, directed staff to monitor and document bowel sounds and the frequency of bowel movements. However, progress notes lacked any documentation of bowel movement monitoring, and the task documentation indicated continence was not rated due to the colostomy, with no recorded amount, frequency, or consistency of stool. During observation, a CNA was seen emptying the resident’s colostomy bag into a plastic trash bag and discarding it without any measurement or documentation of the stool. The CNA stated that staff did not monitor or document the frequency, amount, or consistency of the resident’s bowel movements and did not report this information to the nurse, although the CNA noted the stool was loose. A nurse confirmed that while night shift runs a bowel movement report for residents to check for constipation, staff did not document or monitor this resident’s bowel movements. An administrative nurse stated she expected staff to document and monitor the resident’s bowel movements, and the facility’s ostomy care policy required stool output, consistency, and color to be documented in the chart every shift, which was not done for this resident.
Failure to Administer Ordered Antihypertensives/Diuretics and Notify Physician of Medication Hold
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors and to notify the physician when ordered medications were withheld. The resident had diagnoses of HTN and CHF and was prescribed multiple antihypertensive and diuretic medications, including valsartan 320 mg daily, metoprolol tartrate 50 mg twice daily, furosemide 40 mg daily, and hydrochlorothiazide 12.5 mg daily, all with specific parameters to notify the physician if SBP was less than 90 mm/Hg or greater than 180 mm/Hg, DBP less than 40 mm/Hg or greater than 100 mm/Hg, or pulse less than 50 or greater than 110 on two consecutive checks two hours apart. The resident’s care plan directed staff to administer medications as ordered and monitor blood pressure, holding medications per physician-set parameters. On the date in question, the Medication Administration Record documented that none of the four ordered medications were given, and the EMR notes show that the CMA recorded each medication as held per nursing judgment. According to staff interviews, the CMA obtained a blood pressure reading of approximately 111/49 mm/Hg, rechecked it with the diastolic still in the 40s, and reported this to the nurse. The nurse instructed the CMA to hold the medications based on nursing judgment and confirmed that the physician was not notified. Administrative nursing staff later stated that the nurse did not notify the physician because the blood pressure was not within the parameters requiring provider notification, despite the physician’s orders specifying when to notify. The facility’s Medication Administration Policy stated that medications shall be administered safely as ordered by the physician, but the ordered antihypertensive and diuretic medications were not administered and the physician was not contacted regarding the decision to hold them.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to electronically submit complete and accurate staffing information to the federal regulatory agency through Payroll-Based Journaling (PBJ). Specifically, the facility did not accurately submit hourly staffing data for all nursing personnel for multiple dates across three fiscal quarters in 2023. The review of the PBJ Staffing Data reports for Quarter 2, Quarter 3, and Quarter 4 of 2023 revealed that the facility did not have Licensed Nursing Coverage 24 hours a day on numerous specified dates. Despite the nursing schedule and clocking sheets indicating adequate hours for 24-hour nursing coverage, the data submitted was inaccurate. An interview with Administrative Nurse B on March 27, 2024, revealed that an outside agency contracted by the previous ownership company was responsible for the submission of payroll data prior to November 1, 2023. The administrative nurse was unable to provide an explanation for the inaccurate data. The facility's policy on the mandatory submission of uniform format staffing information (PBJ) stated that the facility would electronically submit complete and accurate direct care staffing information based on payroll and other verifiable and auditable data. The facility administrator was responsible for ensuring the accuracy and timeliness of the submitted data.
Failure to Revise Care Plans for Falls and Nebulizer Use
Penalty
Summary
The facility failed to revise the care plans for four residents, specifically related to falls and the use of nebulizer equipment. For Resident 1, the care plan did not include interventions or staff guidance related to nebulizer treatment for respiratory care, despite physician orders indicating the need for such treatments. Observations revealed that the nebulizer equipment was not properly stored or cleaned between treatments, and interviews with staff indicated a lack of knowledge on how to update care plans using the facility's software program. The facility also failed to provide a policy regarding care plans when requested. For Resident 3, the care plan similarly lacked interventions or staff guidance regarding nebulizer treatments, despite physician orders and observations confirming the need for such treatments. Staff interviews revealed that nebulizers were not being washed between treatments, and there was a general lack of understanding on how to update care plans. The facility again failed to provide a policy regarding care plans when requested. Residents 5 and 13 had multiple falls, but their care plans were not updated with new interventions to prevent further falls. Resident 5 had several falls documented, but the care plan lacked new interventions after each fall. Similarly, Resident 13 had multiple falls, but the care plan was not revised to include new interventions to prevent further incidents. Interviews with staff confirmed that care plans were not being updated, and the facility failed to provide a policy regarding care plan revisions when requested. This deficiency led to additional falls and had the potential for physical and psychosocial injuries for the residents involved.
Failure to Conduct Criminal Background Check for Staff Member
Penalty
Summary
The facility failed to conduct a criminal background check for one of three staff members reviewed, specifically a Certified Nurse Aide (CNA) hired on 07/08/22. During a review of employee files, it was found that the CNA's file lacked any criminal background check information. This was confirmed by the Administrative Nurse, who admitted that she did not know if a background check had been conducted prior to or since the CNA's employment began. The facility's policy on Abuse, Neglect, Exploitation, and Misappropriation Prevention Program mandates that background checks be performed before extending employment offers. The failure to conduct this check had the potential to negatively affect the care delivered to residents.
Failure to Prevent Falls for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident, identified as R13, who had a history of falls and severe cognitive impairment. Despite multiple documented falls and a high fall risk score, the care plan lacked effective interventions to prevent further falls. The resident had several falls within the facility, including incidents where the resident was found on the floor in various locations such as the bathroom, beside the bed, and in front of a recliner. The facility's investigations into these falls often lacked a root cause analysis, and the care plan was not updated with new interventions to prevent additional falls. The care plan for R13 included several interventions, such as ensuring the call light was within reach, placing body pillows on both sides of the bed, and using a video camera at night. However, these interventions were either not effectively implemented or not updated following each fall. Staff interviews revealed that care should be driven by the care plan available in the Electronic Health Record (EHR), but there was a disconnect between the documented care plan and the actions taken by the staff. The facility's policy on accident prevention was not adequately followed, leading to repeated falls for R13. Administrative staff confirmed that the care plan lacked necessary interventions related to each fall and that the facility did not conduct interdisciplinary team meetings or fall huddles to address the issue. The facility's failure to provide a safe environment and adequate supervision resulted in multiple falls for R13, highlighting a significant deficiency in the facility's fall prevention and care planning processes.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care consistent with professional standards of practice for two residents, R1 and R3, regarding the use and cleaning of nebulizers. For R1, the physician's orders included the use of a nebulizer for chronic obstructive pulmonary disease (COPD), but the care plan did not include interventions related to the use and care of the nebulizer. Observations revealed that R1's nebulizer tubing and medication chamber/mouthpiece were improperly stored, and interviews with staff confirmed that the nebulizer was not rinsed between treatments as required. The facility also failed to provide a policy regarding respiratory care when requested. For R3, who had diagnoses of COPD and pleural effusion, the care plan similarly lacked interventions regarding nebulizer treatments. Observations and staff interviews indicated that the nebulizer was not washed between treatments. The facility again failed to provide a policy on respiratory care when requested. These deficiencies highlight the facility's failure to adhere to professional standards of care in providing respiratory treatments to residents.
Failure to Complete Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to complete an annual performance review at least once every 12 months for three Certified Nurse Aides (CNA) to ensure adequate and appropriate care and services were provided to the residents. The facility reported a census of 13 residents. During a review of employee files, it was found that there were no performance evaluations for three CNAs who had been employed for over 12 months. This was confirmed by the Administrative Nurse and Administrative Staff, who acknowledged that it was their expectation to perform annual performance evaluations but admitted that these evaluations were not completed. The facility provided an undated and untitled document indicating that performance evaluations were to be performed at an unknown frequency to measure employee effectiveness and set goals for future performance and professional growth.
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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 Spearville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Manor Of The Plains | 14.9 mi | ★★★★★ | 12 | 0 |
| Trinity Manor | 15.3 mi | ★★★★★ | 0 | 0 |
| Kansas Soldiers Home | 15.9 mi | ★★★★★ | 5 | 0 |
| Sunporch Of Dodge City | 17 mi | ★★★★★ | 1 | 0 |
| Medicalodges Kinsley | 18.7 mi | ★★★★★ | 0 | 0 |
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