Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stanton County Health Care Facility Ltcu during CMS and state inspections, most recent first.
The facility did not employ a full-time Certified Dietary Manager, as the staff member acting in this role was still completing certification and the Registered Dietitian only visited monthly. This resulted in the absence of a fully qualified individual overseeing food and nutrition services for 22 residents, contrary to facility policy.
Staff failed to implement Enhanced Barrier Precautions by using a shared full-body lift sling for a resident with an indwelling urinary catheter, despite physician orders and facility policy requiring targeted PPE and single-resident equipment use during high-contact care. This practice did not align with infection control protocols designed to prevent MDRO transmission.
Several residents received antipsychotic medications without clear clinical indications, proper documentation of risk versus benefit, or consistent implementation of gradual dose reduction protocols. Pharmacist reviews did not address appropriate indications, and physicians did not consistently document clinical justifications for continued use. Staff were often unsure of the reasons for antipsychotic prescriptions, and behavioral interventions were not adequately documented or monitored.
The Consultant Pharmacist did not consistently identify or report medication irregularities, including the lack of appropriate indications for antipsychotic use and missed vital sign monitoring for heart medications. Several residents continued to receive antipsychotics without documented clinical justification, and vital signs were not recorded before administering certain cardiac drugs, with no recommendations or follow-up from the pharmacist. Communication gaps between the pharmacist, DON, and physician contributed to these deficiencies.
Two residents were transferred to the hospital without receiving the required written notification of transfer, including the location and reason for transfer, as mandated by facility policy. Although bed-hold notifications were provided and representatives were notified by phone, the facility did not issue written notices at the time of transfer.
A resident with a mental disorder, psychosocial adjustment difficulty, or a history of trauma and/or PTSD did not receive the necessary treatment and services to address their specific needs, as observed by surveyors.
A resident with severe dementia and multiple comorbidities did not receive individualized, person-centered activities or interventions as required. The care plan lacked specific interests and triggers, and staff had not received specialized dementia behavior training. The resident was observed unengaged in a common area, and the facility did not have a dementia care policy in place.
A deficiency was cited when a resident was found to have been prescribed or administered unnecessary drugs, with no adequate clinical justification documented in the medical record.
A resident's medication cart was found to contain a Lantus insulin pen without a name or date indicating when it was put into use. An LN confirmed the labeling was incomplete, which was not in accordance with the facility's medication storage policy requiring all drugs to be properly labeled.
Lack of Qualified Dietary Manager in Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time Certified Dietary Manager for its census of 22 residents who received meals from the kitchen. During observation, the individual identified as the Dietary Manager was found to be enrolled in a Dietary Manager Certification course but had not yet completed it. The Registered Dietitian was reported to visit the facility only monthly. According to the facility's own policy, a qualified dietitian is required to help oversee clinical nutritional dietary services, with qualifications including registration by the Commission on Dietetic Registration or demonstrated education, training, or experience in dietary needs and program implementation. The lack of a fully qualified Dietary Manager was directly observed during meal preparation.
Failure to Implement Enhanced Barrier Precautions During Resident Transfers
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter, as required by physician orders and the facility's own infection control policy. The resident had multiple diagnoses, including dementia, urinary tract infection, neuromuscular bladder dysfunction, and was dependent on staff for all functional abilities and mobility. The care plan and physician orders specified the use of gowns and gloves during high-contact care activities and directed the use of EBP due to the resident's increased risk for healthcare-acquired infections. Despite these directives, staff used a full-body mechanical lift and shared sling to transfer the resident, and the same sling was also used for two other residents. Observations confirmed that staff donned disposable gloves and gowns during high-contact care, but failed to ensure single-resident use of the lift sling for the resident with an indwelling catheter. The facility's policy emphasized the importance of targeted PPE use and adherence to CDC recommendations to prevent the transmission of multidrug-resistant organisms (MDROs). The shared use of the lift sling, contrary to the care plan and infection control protocols, constituted a failure to fully implement EBP and placed residents at risk for infectious disease transmission.
Failure to Ensure Appropriate Use and Monitoring of Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that several residents were free from unnecessary antipsychotic medication use without appropriate clinical indications, proper documentation of risk versus benefit, or consistent implementation of gradual dose reduction (GDR) protocols. For multiple residents, including those with dementia and behavioral disturbances, antipsychotic medications were administered without clear evidence of specific conditions that would warrant such use, as outlined in the facility's own policy. Documentation in the electronic medical records and care plans often cited general behavioral issues such as yelling, hitting, agitation, and refusal of care as reasons for antipsychotic use, but lacked detailed clinical justification or evidence of failed nonpharmacological interventions. In some cases, the care plans directed staff to attempt GDRs only annually, and when GDRs were recommended by the consultant pharmacist, they were declined by the physician without thorough documentation of clinical contraindications or risk-benefit analysis. Pharmacist medication regimen reviews for the affected residents consistently lacked mention of appropriate indications for antipsychotic use, and there was no evidence that the physician received or acted upon pharmacist recommendations. Administrative staff confirmed that while monthly pharmacy and therapeutics meetings occurred, there was no formal process to ensure the physician reviewed or signed off on pharmacist concerns, nor was there documentation of risk versus benefit rationale for continued psychotropic medication use. Additionally, the facility did not have a mental health provider or social worker regularly assess residents in person or via telehealth, and the contracted social worker did not provide behavioral guidance to staff. Observations of the residents revealed ongoing behavioral symptoms and, in some cases, signs of possible medication side effects such as lethargy and sedation. Staff interviews indicated uncertainty regarding the clinical indications for antipsychotic prescriptions, and care plans often lacked specific behavioral targets or outcomes to monitor the effectiveness of medication interventions. The facility's policy required antipsychotic use only for specific psychiatric conditions, but in practice, medications were used for a broader range of behaviors without adequate documentation or oversight.
Failure to Ensure Adequate Drug Regimen Review and Reporting by Consultant Pharmacist
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) performed adequate monthly drug regimen reviews and appropriately identified and reported medication irregularities to the Director of Nursing (DON) and the Medical Director. Specifically, the CP did not document or communicate the appropriate Centers for Medicare & Medicaid Services (CMS) indications for the use of antipsychotic medications for several residents, despite their ongoing use of these medications for behavioral and psychiatric symptoms. For multiple residents with dementia, major depressive disorder, and other behavioral disturbances, the CP's reviews lacked recommendations or documentation regarding the clinical justification for antipsychotic use, and there was no evidence that the required gradual dose reductions (GDR) or risk versus benefit rationales were consistently addressed or communicated to the physician or DON. Additionally, the CP failed to identify and report missed vital sign monitoring for residents receiving heart medications such as metoprolol, digoxin, and carvedilol. For two residents, medication administration records showed that blood pressure and pulse were not documented prior to the administration of these medications over multiple months, as required by physician orders and standard practice. The CP's monthly reviews did not include recommendations or notations regarding the absence of this critical monitoring, and there was no evidence that these omissions were brought to the attention of the nursing or medical staff. Interviews with administrative nursing staff revealed a lack of clarity and follow-through regarding the pharmacist's responsibilities and communication processes. Although pharmacy and therapeutics meetings were held monthly and the CP completed paper reviews, there was no system in place to ensure that the physician reviewed or signed off on the pharmacist's findings, nor was there a process to ensure that recommendations or concerns were addressed. Facility policy required the CP to communicate potential or actual medication-related problems to the responsible physician and DON, but this was not consistently done, resulting in missed opportunities to address medication safety and appropriateness.
Failure to Provide Written Notification of Hospital Transfer
Penalty
Summary
The facility failed to provide required written notification of transfer to two residents and their representatives when the residents were transferred to the hospital. In both cases, the residents were hospitalized for acute medical needs, and although bed-hold notifications were given and representatives were notified by phone, there was no written notice provided that included the location and reason for transfer, as required. Documentation in the residents' electronic medical records confirmed the transfers and subsequent returns to the facility, but lacked evidence of the mandated written notifications. Staff interviews confirmed that the facility's practice was to notify representatives by phone and document the transfer in progress notes, but not to provide written notification at the time of transfer. Facility policies required written notice for transfers or discharges, including specific information such as the reason for transfer, effective date, location, appeal rights, and ombudsman contact information. However, these procedures were not followed during the unplanned hospital transfers for the two residents reviewed.
Failure to Provide Appropriate Mental Health and Psychosocial Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident who displayed or was diagnosed with a mental disorder, psychosocial adjustment difficulty, or had a history of trauma and/or post-traumatic stress disorder. The deficiency was identified when the resident did not receive the necessary care and interventions tailored to their mental health and psychosocial needs, as required by their condition and history. This lack of appropriate services was observed and documented by surveyors during the review.
Failure to Provide Person-Centered Dementia Care and Activities
Penalty
Summary
The facility failed to provide necessary person-centered activities and interventions for a resident diagnosed with dementia, as required for effective dementia care. The resident had multiple diagnoses, including dementia with psychotic disturbance, anxiety, delirium, congestive heart failure, and atrial fibrillation, and was assessed as having severely impaired cognition. Documentation showed the resident required assistance with most activities of daily living and regularly received antipsychotic and antidepressant medications. The care plan for the resident lacked specific person-centered interventions, did not list individual interests or triggers for negative behaviors, and was not tailored to the resident’s needs. Staff interviews confirmed that the care plan was not specific or person-centered, and staff had not received specialized training on dementia-related behaviors. Observations revealed the resident was left sleeping in a wheelchair in a common area, with no evidence of engagement in meaningful activities as directed by the care plan. The facility also lacked a dementia care policy, and staff acknowledged that care plans for residents with dementia were being updated to include more person-centered interventions. The absence of individualized activities and interventions placed the resident at risk of ineffective treatment and decreased quality of care.
Unnecessary Drugs in Resident Drug Regimens
Penalty
Summary
A deficiency was identified regarding the management of residents’ drug regimens. The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as required by regulations. This indicates that at least one resident was prescribed or administered medications that were not clinically indicated or were excessive in dose or duration, without adequate justification documented in the medical record.
Insulin Pen Found Unlabeled in Medication Cart
Penalty
Summary
During a medication room tour, surveyors observed that a medication cart labeled for a specific resident contained a Lantus insulin pen that was missing both the resident's name and the date the pen was put into use. This observation was confirmed by a licensed nurse, who acknowledged that the insulin pen should have been labeled with the resident's name and the date of first use. The facility's Medication Storage policy requires that all drug containers have complete and legible labels, and that any medications with missing or incomplete labels are to be returned to the pharmacy for proper labeling before storage. The failure to properly label the insulin pen constituted a violation of the facility's policy and accepted professional standards for medication storage.
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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 Johnson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Western Prairie Senior Living Llc | 21.9 mi | ★★★★★ | 20 | 0 |
| Walsh Healthcare Center | 31.9 mi | ★★★★★ | 7 | 0 |
| Stevens County Hospital Ltcu Dba Pioneer Manor | 36 mi | ★★★★★ | 1 | 0 |
| Kearny County Hospital Ltcu | 37.6 mi | ★★★★★ | 0 | 0 |
| Holly Care Center | 39.3 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.