Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Sunporch Of Dodge City during CMS and state inspections, most recent first.
A resident with vascular dementia, anxiety, delirium, major depressive disorder, and severe cognitive impairment was placed in a bed with rails without a documented bed rail safety assessment or informed consent from the resident or representative. Despite multiple residents having beds with at least one rail, nursing staff reported that no bed rail safety assessments had been completed, and maintenance logs showed only general safety checks without specific bed rail inspections. This occurred even though the facility’s bed safety policy required attempts at alternatives, IDT evaluation, resident assessment, and informed consent before using bed rails.
The facility did not complete required annual performance reviews or skills check-offs for two CNAs, as confirmed by administrative staff and employee file review. Both CNAs missed the scheduled skills check-off and had not completed a make-up session, and the facility could not provide a relevant policy when asked.
Multiple residents receiving psychotropic medications did not have timely or appropriate physician responses to pharmacy recommendations for gradual dose reductions, with staff uncertain about escalation procedures and the facility lacking a specific GDR policy, resulting in continued use of potentially unnecessary medications.
Surveyors found that opened food items in the kitchen, freezers, and walk-in cooler were not labeled with open dates, including bread, dairy products, and various frozen foods. The Dietary Manager acknowledged the issue and was unaware of the requirement to label and date opened freezer items. The facility's policy did not specify labeling and dating procedures for opened items.
Staff failed to follow infection control protocols, including proper hand hygiene before and after glove use, correct removal of PPE, and appropriate cleaning of nebulizer equipment after each use. Soiled linens were placed on the floor, and staff did not consistently use required eye protection when handling catheter drainage bags. These lapses were confirmed by staff interviews and direct observation.
Medication and treatment carts containing prescription drugs, narcotics, insulins, and topical medications were found unlocked and unattended in areas accessible to residents, including hallways and an open nurse's office. Nursing staff confirmed the carts should have been locked when not in direct line of sight, and the facility's policy required all medication storage to be secured when not in use. The facility had several residents who were confused and independently mobile at the time of the deficiency.
Three residents experienced significant incidents, including elopement and multiple falls, but their care plans were not promptly revised to reflect new risks or interventions. One resident with Alzheimer's had repeated exit-seeking behaviors and left the facility multiple times before interventions were added to the care plan. Another resident with dementia had several falls, with interventions like fall mats used by staff but not documented in the care plan. A third resident with dementia and Parkinson's disease had multiple falls without appropriate fall investigations or care plan updates. Staff and administrative interviews confirmed delays and inconsistencies in care plan documentation.
The facility did not properly assess or care plan for a resident's smoking safety despite cognitive impairment and failed to conduct thorough fall investigations or implement new interventions for two residents with repeated falls. Staff were unclear about supervision requirements, and required assessments and care plan updates were not completed in a timely manner, resulting in deficiencies in accident prevention.
Nursing staff did not properly clean nebulizer equipment after each medication administration for two residents requiring respiratory care. Instead, equipment was only cleaned once daily, leaving visible liquid residue and not following facility policy or infection control standards.
The facility did not maintain documentation showing that COVID-19 and pneumococcal vaccines were offered or declined for two residents. Administrative staff confirmed the absence of records and the lack of a policy outlining the vaccination process.
Failure to Assess Bed Rail Safety and Obtain Informed Consent
Penalty
Summary
The deficiency involves the facility’s failure to assess a resident for safety related to bed rail use and to obtain informed consent prior to using bed rails. The resident had diagnoses including vascular dementia, anxiety, delirium, and major depressive disorder, with documentation of severe cognitive impairment, memory problems, and being never or rarely understood per the MDS and CAA. The resident’s care plan noted an alteration in musculoskeletal status related to broken bones in the left wrist/forearm, and the facility documented that his bed was replaced with one without bed rails following an incident. However, the resident’s EHR contained no bed rail risk assessment from admission onward, and there was no evidence that the resident or his representative had been provided information about risks and benefits or had given informed consent for bed rail use. Surveyor interviews and record reviews showed that, prior to the incident involving this resident, the facility had no nursing bed rail safety assessment process in place, despite having 25 residents with at least one bed rail attached to their beds. The Administrative Nurse acknowledged that no nursing bed rail safety assessments had been conducted since her hire and confirmed that no informed consent had been obtained for this resident’s bed rail use. Maintenance staff reported performing general safety checks and provided inspection logs that referenced checking for safety and fall risks but did not specifically address bed rails, and there were no inspection logs specific to bed rails. The facility’s own Bed Safety and Bed Rails policy required attempts to use alternatives, IDT evaluation, resident assessment, and informed consent before bed rail use, but these steps were not carried out or documented for this resident.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete an annual performance review or skills check-off for two Certified Nurse Aides (CNAs) within a 12-month period, as required. Review of employee files revealed that these two CNAs, who had been employed for over a year, did not have documented performance evaluations or skills check-offs. Administrative staff confirmed that all CNA staff were required to complete an annual skills check-off in lieu of a performance evaluation, and if a CNA was unable to perform required tasks, remediation would be provided. However, the two CNAs in question missed the most recent skills check-off and had not completed a make-up session as intended. Additionally, the facility was unable to provide a policy related to annual performance evaluations or skills check-off evaluations for CNA staff when requested.
Failure to Ensure Timely Physician Response to Pharmacy Medication Reviews
Penalty
Summary
The facility failed to ensure that physicians responded in a timely manner to monthly medication regimen reviews (MRR) and pharmacy recommendations for gradual dose reductions (GDR) of psychotropic medications for multiple residents. For several residents with diagnoses such as dementia, Parkinson's disease, Alzheimer's disease, and major depressive disorder, the consultant pharmacist made recommendations for GDRs or medication changes, but the attending physicians either did not respond or provided inadequate responses without appropriate rationale. In some cases, the facility made multiple attempts to contact the physicians, but timely follow-up was not achieved, and there was uncertainty among staff regarding the procedures to escalate these issues to the medical director when the attending physician was unresponsive. For example, one resident with moderate cognitive impairment and a history of falls was prescribed antipsychotic and antidepressant medications. The pharmacist recommended a GDR, but the physician did not respond to repeated requests. Another resident with severe cognitive impairment and Alzheimer's disease was on multiple psychotropic medications, and the pharmacist recommended a GDR, but again, there was no documented physician response. In another case, a resident with dementia and anxiety was prescribed antipsychotic, antidepressant, and anti-anxiety medications, and the physician's only response to a GDR recommendation was a brief disagreement without further explanation. The facility's policies stated that if a physician did not respond to MRR recommendations, the consultant pharmacist should contact the medical director or administrator. However, staff interviews revealed a lack of clarity and consistent follow-through on these procedures. Additionally, the facility was unable to provide a policy specific to the GDR process when requested. As a result, the facility did not ensure that residents' medications were free from unnecessary drugs due to the lack of timely and appropriate physician responses to pharmacy recommendations.
Failure to Label and Date Opened Food Items in Storage Areas
Penalty
Summary
Surveyors observed multiple instances of improper food storage in the facility's kitchen and food storage areas. Specifically, two bread bags were found opened without a date, and several items in the freezers, such as bread, rolls, spinach, french fries, onion rings, beef tips, and chicken tenders, were not labeled with an open date. Additionally, items in the walk-in cooler, including a gallon of milk, a container of half and half, grape jelly, ketchup, half of an onion, and a tray of blueberry muffins, were also not labeled with an open date. During an interview, the Dietary Manager confirmed that the undated food items in the refrigerator and the opened bread were unacceptable and admitted to being unaware that freezer items required labeling and dating when opened. The facility's policy addressed safe food expiration guidelines and proper rotation by expiration dates but did not specify the requirement to label and date items when opened in the refrigerator and freezer. No dry food storage policy was provided.
Infection Control Deficiencies in Hand Hygiene, PPE Use, and Equipment Cleaning
Penalty
Summary
Facility staff failed to maintain effective infection control practices during the provision of care to multiple residents. During incontinent care, staff did not perform hand hygiene before donning gloves or after removing gloves and before applying new gloves. Soiled linens were placed directly on the floor instead of on a barrier, and personal protective equipment (PPE) was removed improperly, with gowns and gloves being discarded together without proper technique. Staff interviews confirmed awareness of the correct procedures but acknowledged that these steps were not followed during the observed care. When providing respiratory care, staff did not rinse nebulizer equipment after each medication administration, contrary to facility expectations and professional standards. Instead, nebulizer equipment was only cleaned once daily on the night shift, and used equipment was stored with visible liquid residue in the chamber. Staff interviews confirmed that the expected practice of rinsing and air-drying the equipment after each use was not being followed. Additionally, staff failed to use appropriate PPE, such as eye protection, when emptying or changing catheter drainage bags. Catheter bags were observed resting on the floor, and staff did not follow proper cleaning protocols when this occurred. The facility's own policies required hand hygiene after glove removal and the use of eye protection for splash hazards, but these were not consistently implemented during care.
Unattended and Unlocked Medication and Treatment Carts
Penalty
Summary
Surveyors observed that both a medication cart and a nurse treatment cart containing prescription medications, narcotics, over-the-counter medications, insulins, topical ointments, medicated creams, and wound care supplies were left unlocked and unattended in resident-accessible areas. On one occasion, the medication cart was found in a hallway with keys hanging from the locking mechanism, and the treatment cart was also unlocked and unattended, with multiple staff members passing by without securing them. Licensed nursing staff confirmed that these carts contained controlled substances and other medications and acknowledged that the carts should be locked when not in direct line of sight of the responsible nurse. Further observations revealed that the nurse treatment cart was left unlocked and unattended in the nurse's office, with the door open and accessible from resident hallways. Interviews with nursing staff confirmed that the carts should remain locked when not within arm's reach, regardless of their location. The facility had 12 residents identified as confused and independently mobile. The facility's own policy required all medication storage compartments to be locked when not in use and not left unattended if open or accessible to others. The failure to secure these carts resulted in a deficiency related to the safe storage of drugs and biologicals.
Failure to Revise and Update Care Plans After Elopement and Falls
Penalty
Summary
The facility failed to accurately revise and update care plans for three residents following significant changes in their conditions and incidents, as observed through record review, staff interviews, and direct observation. One resident with Alzheimer's disease and severely impaired cognition exhibited increased exit-seeking behaviors and experienced actual elopements on multiple occasions. Despite repeated incidents of wandering and leaving the facility, the care plan was not updated to include appropriate interventions for exit-seeking and elopement behaviors until after several events had already occurred. Staff interviews confirmed that care plan updates were not always timely, and administrative staff were sometimes unaware of incidents that should have triggered care plan revisions. Another resident with dementia and severely impaired cognition experienced multiple falls, including one that resulted in a large hematoma and hospitalization. Although immediate interventions such as increased monitoring and toileting assistance were implemented following these falls, these interventions were not promptly incorporated into the resident's care plan. Staff interviews revealed that some interventions, such as the use of a fall mat, were being provided but were not documented in the care plan, leading to inconsistencies in communicated care needs. Administrative staff acknowledged that delays of up to 30 days in updating care plans after a fall were unacceptable. A third resident with dementia and Parkinson's disease experienced several falls, some with minor injuries, but the facility failed to conduct appropriate fall investigations or develop and document root cause analyses and immediate or permanent care plan interventions. Progress notes and fall reports lacked documentation of interventions to mitigate fall risks, and care plans were not revised to reflect new or ongoing risks. Staff interviews confirmed that while immediate interventions were discussed and sometimes implemented, these were not consistently documented in the care plan, resulting in uncommunicated care needs.
Failure to Assess and Care Plan for Smoking and Fall Risks
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for multiple residents. One resident with a history of depression, repeated falls, hypotension, and cognitive impairment was not properly assessed for smoking safety upon admission. There was no documentation of a smoking evaluation or care plan for this resident's smoking privileges until 78 days after admission, despite evidence that the resident was a current smoker and had access to cigarettes and a lighter. Staff interviews revealed confusion and lack of clarity regarding the resident's smoking status and required supervision, with some staff believing supervision was needed and others allowing independent smoking without proper assessment or care planning. The facility's own policy required a smoking evaluation and care plan upon admission, which was not followed in this case. Another resident with diagnoses including dementia and Parkinson's disease experienced multiple falls, but the facility failed to conduct appropriate fall investigations or implement and document new interventions to mitigate the risk of further falls. Several falls were reported in the resident's record, but the associated fall reports lacked root cause analysis, immediate interventions, and updates to the care plan. Staff interviews confirmed that while there was an expectation for immediate intervention and care plan updates after a fall, these actions were not consistently documented or implemented. Administrative staff acknowledged that fall investigation reports were incomplete and that care plan interventions were not always entered in a timely manner. The facility's policies required timely assessment, investigation, and care planning for both fall prevention and resident smoking safety. However, the records and staff interviews demonstrated that these procedures were not consistently followed. The lack of timely and thorough assessments, investigations, and care plan updates for residents at risk for falls and those who smoke resulted in deficiencies that could potentially lead to injury.
Failure to Clean Nebulizer Equipment After Each Use
Penalty
Summary
Licensed nurses failed to properly clean nebulizer equipment after each use for two residents who required respiratory care. Observations showed that after administering breathing treatments, staff placed used nebulizer equipment into bags without rinsing them, leaving visible liquid residue in the chambers. Interviews with nursing staff confirmed that the nebulizer equipment was only cleaned and rinsed once daily during the night shift, rather than after each medication administration as required by facility policy and infection control standards. The facility's policy specified that nebulizer containers should be rinsed with fresh tap water and dried on a clean paper towel or gauze sponge after each use. However, both direct observation and staff interviews revealed that this procedure was not followed. The infection control nurse stated that her expectation was for nurses to rinse the nebulizer after each use and allow it to air dry, but this was not being done. This failure to adhere to proper cleaning protocols for respiratory equipment constituted a deficiency in providing safe and appropriate respiratory care.
Failure to Document and Offer Required Vaccinations
Penalty
Summary
The facility failed to provide proper documentation regarding the administration or declination of COVID-19 and pneumococcal vaccines for two residents. Specifically, the electronic health record for one resident did not contain evidence that the COVID-19 vaccine was offered or declined, and for another resident, there was no documentation of either the pneumococcal or COVID-19 vaccines being administered or declined. Administrative staff confirmed that the required documentation could not be located, and one resident was not offered the COVID-19 vaccine because they were not present in the facility when it was administered. Additionally, the facility was unable to provide a policy specific to the process for administering or documenting pneumococcal or COVID-19 vaccines when requested by surveyors.
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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 Dodge City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kansas Soldiers Home | 1.6 mi | ★★★★★ | 5 | 0 |
| Manor Of The Plains | 2.9 mi | ★★★★★ | 12 | 0 |
| Trinity Manor | 3.1 mi | ★★★★★ | 0 | 0 |
| Southwind At Spearville | 17 mi | ★★★★★ | 19 | 0 |
| The Shepherd's Center | 18.4 mi | ★★★★★ | 24 | 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.