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 The Cedars during CMS and state inspections, most recent first.
A resident with moderately impaired cognition had their blood glucose checked by an LN at a dining room table in the presence of other residents, staff, and a visitor. After obtaining the reading from the resident’s finger, the LN announced that the blood sugar was high and that the MD might need to be contacted to start insulin. Administrative nursing staff later acknowledged that such procedures should occur in a private area, and facility policy stated that residents have the right to be treated with dignity and respect.
The facility failed to provide required Notice of Medicare Non-Coverage (NOMNC) forms to two residents when their skilled services ended. In both cases, there was no documentation that the residents or their representatives received Form CMS-10123, which explains non-coverage and the appeal process. An administrative staff member confirmed the forms were not given as required, and the facility could not produce a policy for Beneficiary Notices when requested by surveyors.
Surveyors found that the facility did not ensure appropriate indications and documentation for psychotropic medications. A resident with dementia, depression, Parkinson’s disease, and encephalopathy received an antipsychotic for dementia with agitation without a documented physician rationale, nonpharmacological interventions, or risk–benefit analysis as required by facility policy. Two other residents with dementia, depression, and anxiety had PRN antianxiety medications ordered without 14-day stop dates or specified durations, and their records lacked the required physician rationale for extended PRN use, despite staff acknowledging that such orders should include a 14-day limit and reassessment.
A resident with dementia, acute blood loss anemia, and a lower GI bleed, who required partial staff assistance with ADLs and had moderately impaired cognition per MDS BIMS, was admitted for care and later discharged home with a spouse. The care plan identified discharge as an outcome and directed staff to support the resident and family through care plan conferences, discharge planning, and discussion of alternative care options. Despite this, the clinical record did not contain a recapitulation summarizing the resident’s stay and course of treatment at discharge, and facility leadership confirmed that this required discharge documentation was not completed, contrary to the facility’s discharge planning policy.
Surveyors found that the facility failed to implement appropriate care planning and clinical parameters for two residents. A resident with DM who was dependent for mobility and received daily insulin had a care plan that only directed staff to provide a nighttime protein snack, with no further diabetes-related guidance, and the EMR lacked physician-ordered blood glucose parameters despite orders for pre-meal and bedtime checks; nursing staff and a CMA confirmed there were no parameters in the current EMR and that they relied on nursing judgment. Another resident with dementia, anxiety, severely impaired cognition, and a history of repeated falls was identified as high fall risk, yet the care plan contained only general directions such as determining causative factors, promoting exercise, and obtaining PT and pharmacy reviews, without specific individualized fall interventions. Multiple fall investigations documented the resident repeatedly scooting onto the floor in her room, with immediate responses limited to adding a fall mat and posting reminder signs, while staff reported frequent falls, use of a Wander Guard, and the practice of keeping the resident in common areas for observation.
Two residents at high risk for falls experienced multiple falls when staff did not consistently follow fall-prevention care plans and safe transfer practices. One resident with dementia and Parkinson’s disease, who required staff assistance and had a history of falls, continued to ambulate in shoes that were too large, leading to a fall with laceration, hematoma, and skin tear during assisted walking, despite a care-plan directive for properly fitting footwear. The same resident had several prior unwitnessed falls from a recliner in his room, with at least one fall lacking a documented investigation in the EMR, contrary to facility fall-reporting policy. Another resident with severe cognitive impairment, macular degeneration, and weakness, care-planned for two-person assistance with a sit-to-stand lift, slid out of the sling and fell to the bathroom floor on two occasions during sit-to-stand transfers; investigations identified incorrect sling application and use of only one staff member during one event, inconsistent with the care plan and facility policies requiring appropriate interventions and documentation after falls.
A resident with diabetes who was dependent on staff for care and received daily insulin had blood sugars checked four times per day without any physician-ordered blood glucose parameters documented in the EMR or care plan. Nursing staff reported relying on personal judgment to determine when to notify the physician, and a CMA stated she did not know what the parameters should be, noting that they were present in a prior computer system but not in the current one. An administrative nurse acknowledged that physician-ordered parameters and clear care plan directions for diabetes management were lacking, and the facility could not provide a blood sugar management policy when requested.
A resident with dementia, metabolic encephalopathy, DM, atrial fibrillation, and chronic pain experienced a decline in ADLs and was admitted to hospice for senile degeneration of the brain. The MDS documented hospice services and increased need for assistance, but the facility’s care plan did not include any information that the resident was on hospice or reflect coordination with hospice services. An administrative nurse confirmed the omission, despite a facility end-of-life policy requiring interdisciplinary care planning for hospice and end-of-life care.
The facility did not employ a full-time certified dietary manager while providing meals to 33 residents. A dietary staff member preparing meals confirmed she was not certified and was still completing coursework and testing for certification, yet was responsible for managing specialized diets, including pureed diets for two residents and minced and moist diets for three residents. Administrative staff later verified that this staff member was not certified, despite facility policy requiring sufficient competent personnel in the food and nutrition services department.
A facility failed to report an allegation of rough care as potential abuse to the LNHA and SA. A resident with severe cognitive impairment and other medical conditions was reportedly handled roughly by a CMA during a transfer, leading to the resident yelling out. Despite a CNA witnessing and reporting the incident, it was not immediately reported to the LNHA or SA, placing the resident at risk for ongoing mistreatment.
A resident with severe cognitive impairment and multiple medical conditions was allegedly handled roughly by a CMA during a transfer, leading to the resident yelling out. Despite the report of potential abuse, the facility did not immediately suspend the involved staff member or conduct a thorough investigation, as required by policy. This delay in action placed the resident at risk for continued abuse.
Public Blood Glucose Testing and Discussion Compromised Resident Dignity
Penalty
Summary
The facility failed to protect and promote the dignity of Resident 23, who had a Brief Interview for Mental Status (BIMS) score of 11 indicating moderately impaired cognition, when obtaining and discussing blood glucose results in a public setting. On 01/21/26 at 7:55 AM, a licensed nurse checked the resident’s blood sugar using a glucometer while the resident was seated at a dining room table, with five other residents, staff, and a visitor present. After obtaining the reading from the resident’s right index finger, the nurse verbally stated in the dining room that the resident’s blood sugar was high and that the physician might need to be contacted to start insulin. Administrative staff later confirmed that blood sugar checks should not be performed in the dining room and that residents should be taken to their room or a private area, and facility policy on resident rights documented that residents have the right to be treated with dignity and respect. This conduct, occurring in a communal dining area in the presence of other residents, staff, and a visitor, constituted a failure to provide care in a manner that maintained Resident 23’s dignity and respected their right to privacy regarding personal health information.
Failure to Provide Required Medicare Non-Coverage Notices to Beneficiaries
Penalty
Summary
The facility failed to provide required Medicare beneficiary notices to two residents whose skilled services were ending, resulting in a deficiency related to lack of Notice of Medicare Non-Coverage (NOMNC) Form CMS-10123. For one resident, skilled services ended on 11/20/25, and for the other resident, skilled services ended on 01/13/26; in both cases, the facility lacked documentation that the resident or their representative received Form 10123, which should have included a detailed explanation of non-coverage and the appeal process. During an interview on 01/23/26 at 1:40 PM, an administrative staff member confirmed that Form 10123 was not provided to these two residents and acknowledged that it should have been given to the resident or representative. Additionally, when requested on 01/23/26, the facility was unable to provide a policy for Beneficiary Notices.
Failure to Ensure Appropriate Indications and 14-Day Limits for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate indications and documentation for psychotropic medication use, including antipsychotic and PRN antianxiety drugs. One resident with diagnoses of dementia, depression, Parkinson’s disease, and encephalopathy was admitted post-hospitalization and had severely impaired cognition, requiring staff assistance with most ADLs. This resident received Seroquel 25 mg twice daily for a diagnosis of dementia with agitation. The care plan documented monitoring for side effects and effectiveness, but the electronic medical record lacked a documented physician rationale for the continued use of Seroquel, including documentation of unsuccessful attempts at nonpharmacological symptom management and a risk-versus-benefit analysis. An administrative nurse confirmed that the resident was receiving an antipsychotic with a diagnosis of dementia, which was identified as an inappropriate indication under facility policy, and that the physician and consultant pharmacist had recognized the need for a different diagnosis. The facility’s own Antipsychotic Medication Administration policy required that antipsychotics only be used when necessary to treat a specific, documented condition and that orders include a diagnosis, condition, or indication for use from a defined list of acceptable conditions. The policy also required comprehensive assessment, routine dose reduction, and behavioral interventions unless clinically contraindicated. Despite these requirements, the documentation for the resident on Seroquel did not include the necessary physician rationale or evidence of nonpharmacological interventions attempted prior to or alongside antipsychotic use, as required by the policy. The deficiency also includes failures related to PRN antianxiety medications for two other residents with dementia, depression, and anxiety diagnoses and severely impaired cognition. One resident had a physician’s order for alprazolam 0.5 mg by mouth every eight hours PRN for anxiety, and another had an order for lorazepam 0.5 mg by mouth every four hours PRN for anxiety. Both orders lacked a 14-day stop date or any specified duration. Their electronic medical records did not contain evidence of a physician’s rationale for extended PRN use, including a risk-benefit rationale statement and duration, as required by the facility’s Psychotropic Medication Use policy. Nursing staff acknowledged that PRN psychotropic orders were supposed to have a 14-day stop date and that the physician should reassess the residents to determine ongoing need, but this had not been implemented in these cases.
Failure to Complete Discharge Recapitulation for Resident Stay
Penalty
Summary
The deficiency involves the facility’s failure to complete a recapitulation of a resident’s stay and course of treatment upon discharge. The resident had diagnoses of dementia, acute blood loss anemia, and a lower gastrointestinal bleed, and an admission 5-Day Medicare MDS documented a BIMS score of nine, indicating moderately impaired cognition. The resident required partial staff assistance with toileting hygiene, showers, dressing, personal hygiene, and transfers. The care plan documented that the resident was to be discharged from the facility and directed staff to encourage verbalization of fears and concerns, clarify misconceptions, and provide the resident and family with opportunities to attend care plan conferences, participate in discharge planning, and consider alternative care options. Nurse’s notes documented that the resident was admitted with a lower gastrointestinal bleed and anemia and later discharged home with her husband. However, the clinical record lacked a completed recapitulation summarizing the resident’s stay and course of treatment in the facility. On interview, the Administrative Nurse confirmed that a recapitulation upon discharge was not completed for this resident. The facility’s Discharge Planning policy stated that discharge planning is part of the comprehensive care plan and that all discharge planning activities are to be documented in the resident’s clinical record, but the required recapitulation was not present in this case.
Failure to Implement Diabetes Management Parameters and Individualized Fall Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate care planning and clinical parameters for a resident with diabetes mellitus. One resident with a documented diagnosis of diabetes had an admission MDS showing intact cognition and dependence on staff for toileting hygiene, mobility, and transfers, and received daily insulin. The resident’s care plan directed staff only to provide a nighttime protein snack to keep blood sugars even and did not include any further direction related to diabetes management. A physician order required blood sugars to be obtained before meals and at bedtime for diabetes, but the medical record did not contain any blood sugar parameters. A licensed nurse confirmed there were no parameters and stated he would use his own nursing judgment to decide when to notify the physician, and a CMA reported not knowing what the parameters should be, noting that parameters had existed in a prior computer system but were absent in the new one. An administrative nurse stated the resident should have physician-ordered blood sugar parameters and that the care plan should direct staff on what to monitor for regarding the resident’s diabetes. The deficiency also includes failure to implement individualized fall interventions for another resident with dementia, anxiety, repeated falls, and severely impaired cognition. This resident was dependent on staff for ambulation, toileting hygiene, and lower-body dressing, and required substantial assistance for mobility and supervision with transfers. The admission MDS documented that the resident was at risk for falls, had no functional impairment, and had experienced two or more falls since admission. The care plan instructed staff to determine and address causative factors of falls, provide exercise and strength-building activities, obtain a PT consult for strength and mobility, and request a pharmacist medication review, but did not include specific, individualized fall interventions beyond these general directions. Multiple fall assessments and investigations documented that the resident was at high risk for falls and had several episodes of being found on the floor after scooting herself in her room, often near the room door, with falls described as unwitnessed and without injury. Immediate interventions documented in the fall investigations included obtaining a fall mat and placing signs in the room to remind the resident to call for help before attempting to transfer. Observations showed the resident in a low bed with a fall mat, able to stand with a gait belt and ambulate steadily with a walker, and staff reported she had numerous falls in her room, wore a Wander Guard that alarmed frequently, and was often placed in a recliner in the dayroom so staff could watch her. An administrative nurse stated that the resident had many falls in her room and that staff should have put interventions in place for those falls, and further confirmed that all the incidents where she scooted on the floor in her room were considered falls. The facility’s Resident Care Plan policy required evaluation by the interdisciplinary team, initiation of a care plan within 48 hours of admission, and review and revision of the care plan when resident needs changed, but the documented care plans did not reflect individualized interventions for the resident’s repeated falls.
Failure to Follow Fall-Prevention Care Plans and Safe Transfer Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and follow fall-prevention care plans for two residents at high risk for falls. One resident (R9) had dementia without behavioral disturbance and Parkinson’s disease, with documented high fall risk and multiple prior falls. His care plan included multiple fall-prevention interventions, including a directive for the family to provide properly fitting shoes. Despite this, R9 continued to use shoes that were too big, and during an assisted walk with a gait belt and walker he tripped over his feet and fell, sustaining a laceration to the left eyebrow, a hematoma, and a skin tear to the left elbow, requiring emergency room evaluation and wound closure. The fall investigation specifically identified that his shoes were too big, and an administrative nurse acknowledged that the oversized shoes contributed to the fall and that staff should have followed the fall care plan intervention. R9’s records also showed repeated falls in his room and from his recliner prior to the injury fall. On multiple occasions, staff heard a crash from his room and found him on the floor next to his recliner or air conditioner/heater unit after he attempted to get up or prepare his bed. Although his care plan directed staff to place the call light and personal items within reach, educate him to use the call light for assistance, offer a urinal every two hours, and encourage use of the dayroom for supervision when restless, he continued to experience falls in his room. One nurse’s note documented a fall from his recliner with staff then moving him to the dayroom for visualization, but the electronic medical record lacked a corresponding fall investigation for that event, despite facility policy requiring completion of a Fall Report and further investigation after any fall. The second resident (R43) had dementia with severely impaired cognition, macular degeneration, repeated falls, and weakness, and was assessed as high risk for falls. Her care plan included use of a fall mat, staff education on proper sling placement, and a requirement for two staff with a sit-to-stand lift for transfers. She experienced two separate falls during sit-to-stand lift transfers to or from the toilet. In the first incident, her knees gave out and she slid out of the sling onto the bathroom floor. In the second incident, she let go of the lift, slid through the belt on the sling, and fell onto her bottom. In both cases, the fall investigations identified issues with the use of the sit-to-stand lift and sling, including that the sling was not put on correctly and that only one staff member was present during one of the falls, contrary to the care plan directive for two-person assistance. Staff interviewed later were unaware of these prior sit-to-stand falls and described her as a one-to-two-person transfer who could use the sit-to-stand lift if needed, indicating that the care plan directions and fall history were not consistently followed in practice. Facility policies on Falls-Accident Reporting and the Resident Fall Checklist required that after any fall, licensed staff complete a Fall Report, perform a head-to-toe assessment before assisting the resident off the floor, notify the physician and responsible party, determine appropriate interventions to prevent further falls, update the care plan, obtain witness statements for falls with injury or possible injury, and document progress notes every shift for three days. The documented events for R9 and R43 show that falls occurred in the context of high fall risk, existing fall-prevention care plans, and specific policy requirements, yet the facility did not consistently implement the care-planned interventions (such as ensuring properly fitting shoes and two-person sit-to-stand transfers) or fully document and investigate all falls as required by its own policies.
Lack of Physician-Ordered Blood Glucose Parameters for Insulin-Dependent Diabetic Resident
Penalty
Summary
Surveyors identified a deficiency related to unnecessary drugs and inadequate blood glucose management for one resident with diabetes mellitus. The resident had a diagnosis of diabetes, was cognitively intact with a BIMS score of 13, and was dependent on staff for toileting hygiene, mobility, and transfers. The MDS documented that the resident received insulin daily, and the care plan directed staff to provide a nighttime protein snack to keep blood sugars even, but the care plan did not include specific directions related to diabetes management. A physician order directed staff to obtain blood sugars before meals and at bedtime, yet the medical record lacked any physician-ordered blood sugar parameters. During interviews, a licensed nurse confirmed that there were no blood sugar parameters for the resident and stated he relied on his own nursing judgment to decide when to notify the physician if blood sugars seemed too high. A CMA reported that she did not know what the resident’s blood sugar parameters should be and stated that parameters had existed in a previous computer system but were absent in the new system. An administrative nurse acknowledged that the resident should have physician-ordered blood sugar parameters and that the care plan should provide direction to staff regarding the resident’s diabetes. When requested, the facility was unable to provide a policy for blood sugar management.
Failure to Coordinate Facility and Hospice Care in Resident Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure coordinated care and services between the facility and hospice for a resident receiving hospice services. The resident had diagnoses including dementia, metabolic encephalopathy, DM, atrial fibrillation, and chronic pain, and a Significant Change MDS showed a BIMS score of eleven, indicating moderately impaired cognition. The MDS documented that the resident required extensive staff assistance with toilet hygiene and supervision with oral hygiene, personal hygiene, and other ADLs, and that the resident was receiving hospice services. The ADL care plan noted a decline in the resident’s ability to care for herself after a fall in assisted living, with increased confusion, several falls, and increased need for staff assistance with most ADLs. Despite the resident’s admission to hospice on 11/14/25 with a diagnosis of senile degeneration of the brain, review of the clinical record showed that the facility’s care plan did not contain any information indicating that the resident was on hospice services. On observation, the resident was seen dressed in street clothes and eating breakfast at the dining room table. During an interview, an administrative nurse confirmed that the facility care plan lacked any indication that the resident was receiving hospice services and verified that the resident had been on hospice since 11/14/25. The facility’s End of Life policy stated that end-of-life care, including hospice, should be provided through an interdisciplinary approach with a care plan developed by the team to address actual and potential problems, but this coordination with hospice was not reflected in the resident’s care plan.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to provide the services of a full-time certified dietary manager for 33 residents who received their meals from the kitchen. During observation of lunch meal preparation, a dietary staff member confirmed she was not a certified dietary manager, reported she was still taking the course and had not yet taken the certification test, and was functioning in the kitchen despite this. She also identified that two residents were on a pureed diet and three residents were on a minced and moist diet. Later, administrative staff confirmed that this dietary staff member was not certified. The facility’s Personnel policy stated that the food and nutrition services department would be staffed with sufficient competent personnel to carry out departmental functions, but the facility did not have a certified dietary manager in place. No additional resident-specific medical histories or conditions beyond the need for pureed and minced and moist diets were documented in the report.
Failure to Report Alleged Rough Care as Potential Abuse
Penalty
Summary
The facility failed to ensure that staff identified and reported an allegation of rough care as potential abuse immediately to the Licensed Nursing Home Administrator (LNHA) and the State Agency (SA) as required. This deficiency was identified during a survey involving a resident with severe cognitive impairment, dementia, hypertension, and other medical conditions. The resident was dependent on staff for various aspects of personal care and had a history of verbal behaviors and care refusal. On a specific date, a Certified Nurse Aide (CNA) witnessed a Certified Medication Aide (CMA) handling the resident roughly during a transfer, which resulted in the resident yelling out. The CNA reported the incident to a Licensed Nurse (LN), who then informed Administrative Nurse D via email. However, the incident was not reported to the LNHA or the SA immediately, as required by the facility's policy on abuse, neglect, and exploitation prevention. The failure to report the incident promptly placed the resident at risk for ongoing abuse and mistreatment. Despite the CNA's report and the subsequent examination of the resident, which found no new bruising, the facility did not take the necessary steps to ensure the allegation was addressed according to regulatory requirements. This oversight highlights a significant lapse in the facility's abuse reporting protocol.
Failure to Investigate and Protect Resident from Alleged Abuse
Penalty
Summary
The facility failed to initiate protective measures and fully investigate an allegation of abuse involving a resident with severe cognitive impairment and multiple medical conditions, including dementia and major depressive disorder. The resident was dependent on staff for various aspects of care and had a history of verbal behaviors and care refusal. On a specific date, a Certified Nurse Aide (CNA) reported witnessing a Certified Medication Aide (CMA) potentially handling the resident roughly during a transfer, which was followed by the resident yelling out in distress. Despite the report of potential abuse, the facility did not immediately suspend the involved staff member or conduct a thorough investigation. The incident was initially reported to a Licensed Nurse (LN), who noted typical bruising on the resident's arms but did not find any new bruising. The LN communicated the concern to an Administrative Nurse, but the information was not promptly relayed to the appropriate administrative staff for further action. This delay in communication and action resulted in the staff member continuing to work with residents until a later date when the issue was escalated. The facility's policy required immediate reporting and suspension of staff involved in alleged abuse, but these procedures were not followed. The failure to adhere to the policy and promptly address the allegation placed the resident at risk for continued abuse. The lack of immediate protective measures and a comprehensive investigation highlights a significant deficiency in the facility's handling of abuse allegations.
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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 Mcpherson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mcpherson Operator, Llc | 1.2 mi | ★★★★★ | 0 | 0 |
| Pleasant View Home | 12 mi | ★★★★★ | 0 | 0 |
| Bethany Home Association | 13.8 mi | ★★★★★ | 2 | 0 |
| Moundridge Manor | 13.9 mi | ★★★★★ | 0 | 0 |
| Pine Village | 15.1 mi | ★★★★★ | 0 | 0 |
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