Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Shepherd's Center during CMS and state inspections, most recent first.
The facility did not complete required annual performance evaluations for two of five sampled CNAs, as shown by missing or outdated evaluation records in their personnel files.
A facility failed to employ a full-time certified dietary manager with appropriate credentials to oversee food and nutrition services for its residents. The current Dietary Manager did not have certification or prior food handling experience and was only enrolled in certification classes at the time of the survey. Administrative staff were unaware of the requirement for certification or specialized training, and the facility could not provide a relevant policy or evidence of adequate training.
Surveyors found that food was not stored or handled according to sanitary standards, with undated and expired items, frost-covered vegetables, and missing freezer temperature logs in multiple kitchens. Administrative staff confirmed that required procedures for dating, discarding, and monitoring food were not followed, resulting in unsanitary conditions.
The facility did not complete a thorough facility-wide assessment to identify specific staffing levels, shift requirements, or contingency staffing plans needed to care for all residents during daily operations and emergencies. The assessment lacked details on the number of RNs, LPNs, CMAs, and CNAs required for each unit and shift, and did not include plans for staffing during events that could impact resident care.
The facility did not complete a required QAPI PIP within the past year, with administrative staff unable to provide evidence of any recent PIP activity and stating the last one was completed about a year and a half ago, contrary to facility policy.
The facility did not maintain required infection and antibiotic surveillance logs, and the Infection Preventionist was unable to provide documentation of infection data collection or analysis. Instead, infection monitoring was limited to daily EMR reviews for new antibiotic orders and verbal reporting at QA meetings, contrary to facility policy requiring systematic documentation and analysis.
Staff did not maintain required antibiotic and infection surveillance logs, and the Infection Preventionist had no records to show tracking or analysis of antibiotic use or lab reports. Instead, antibiotic monitoring was limited to daily EMR review and verbal reporting at QA meetings, contrary to facility policy requiring comprehensive documentation and analysis.
The facility did not complete or submit comprehensive MDS assessments on time for multiple residents, with delays ranging from several days to over a month, and in one instance, an assessment remained incomplete. This was confirmed by review of medical records and staff interviews, despite facility policy requiring timely and accurate MDS completion.
A resident with a history of frequent falls and stroke was discharged without receiving written notification or a completed recapitulation of stay. The facility did not provide or have the resident or responsible party sign any discharge paperwork, and staff interviews confirmed that required discharge documentation was not completed in the electronic medical record.
A resident with anxiety, depression, and insomnia was administered multiple psychotropic medications, including an antipsychotic and a hypnotic, but the MDS assessment failed to document the use of these medications during the required lookback period. Staff interviews and record reviews confirmed the omission, which was not in accordance with facility policy for accurate MDS completion.
A resident admitted with a history of myocardial infarction and major depression did not have a Baseline Care Plan developed within 48 hours of admission, as required by facility policy. Review of the electronic medical record and staff interviews confirmed the absence of this initial care plan, which is intended to guide immediate care and ensure staff communication.
A resident with a history of myocardial infarction and major depression, who was cognitively intact and independent in ADLs but exhibited care rejection behaviors, did not have a comprehensive care plan documented in the EMR as required by facility policy. This omission was confirmed by administrative staff.
A resident with a pressure ulcer did not have wound care interventions included in their care plan, despite physician orders for wound treatment. The care plan only addressed cardiac issues, and a nurse confirmed the omission. Facility policy requires individualized care plans, but this was not followed for the resident's wound care needs.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete the required annual performance evaluations for two out of five sampled Certified Nursing Aides (CNAs). Review of personnel files showed that one CNA, hired in August 2023, had a performance evaluation dated July 2024 with no subsequent evaluation documented. Another CNA, hired in December 2020, had a performance evaluation dated May 2024 with no further evaluation recorded. This deficiency was identified through interviews and record reviews, confirming that the facility did not ensure timely completion of annual evaluations as required.
Lack of Certified Dietary Manager for Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee the food and nutrition services for its 20 residents. During interviews, the current Dietary Manager stated she did not possess a CDM certificate or prior experience with food handling before assuming the position and was only currently enrolled in CDM classes. Administrative staff confirmed that the Dietary Manager was placed in the role without knowledge of the certification, specialized training, or experience requirements. Additionally, the facility was unable to provide evidence of adequate training credentials for the Dietary Manager or a policy regarding the employment of a Certified Dietary Manager.
Unsanitary Food Storage and Handling Practices Identified
Penalty
Summary
Surveyors observed that the facility failed to prepare and serve food under sanitary conditions, as required by professional standards and facility policy. During inspections of the main pantry and two satellite kitchens, they found a dented can of refried beans, bags of carrots with significant frost accumulation, and hash browns without a date. In the satellite kitchens, there were bags of hot dogs—one with an expired date and another with no date—as well as additional bags of carrots with frost. The mini freezer temperature logs were not maintained for several days, and upon re-inspection, the logs still had not been updated. Additionally, neither of the two kitchens had foot-activated trash cans available, contrary to sanitary best practices. Interviews with administrative staff confirmed that staff were expected to date food items when opened and discard outdated items, and that freezer temperatures were to be checked and logged daily. Facility policy also required that food items be checked, dated, and stored properly, and that food from dented cans or with abnormal appearance be discarded immediately. The observed failures to follow these procedures resulted in unsanitary food storage and handling practices, placing residents at risk for foodborne illness.
Incomplete Facility-Wide Assessment for Staffing and Resource Needs
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources required to care for its 20 residents competently during both routine operations and emergencies. The assessment provided did not specify the required staffing levels for each unit, nor did it detail the number of RNs, LPNs, CMAs, and CNAs needed based on patient acuity and census. Additionally, the assessment lacked information on staffing requirements for each shift, including evenings and weekends, and did not include contingency staffing plans for situations that could impact resident care but did not necessitate activation of the emergency plan. During interviews, administrative staff acknowledged that while some staffing information had been updated, the assessment did not include all required elements such as specific staffing levels, contingency staffing plans, or staff recruitment plans. The facility's own policy requires an annual evaluation of resident population and identification of necessary resources, including sufficient staff and appropriate competencies for all shifts, as well as contingency planning for events affecting resident care. However, the assessment reviewed did not meet these requirements, affecting all residents in the facility.
Failure to Complete Required Quality Assurance and Performance Improvement Program
Penalty
Summary
The facility failed to complete a Quality Assurance and Performance Improvement Program (PIP) within the past year, as required by its own policy. Upon request, the facility was unable to provide evidence of any PIP completed in the last year. During an interview, an administrative staff member stated that she expected the administrative nurse to complete all PIPs and believed the last PIP was completed approximately one and a half years ago. The facility's policy indicated that PIPs should be developed and maintained to address care and service areas needing attention, based on data-driven indicators and prioritization tools. However, no documentation or evidence of such activities was available for the past year.
Failure to Maintain Infection Surveillance and Documentation
Penalty
Summary
The facility failed to implement a comprehensive infection prevention and control program for its 20 residents. Specifically, the facility did not maintain antibiotic and infection surveillance logs, and the Infection Preventionist was unable to provide any electronic or paper records documenting the collection and analysis of infection data. Instead, the Infection Preventionist relied on daily reviews of the Electronic Medical Record for new antibiotic orders and provided only verbal reports of infections and antibiotic use during Quality Assurance meetings. This practice was inconsistent with the facility's own policy, which required systematic monitoring, documentation, and analysis of infection data through a monthly infection control log and ongoing surveillance.
Failure to Monitor and Document Antibiotic Stewardship
Penalty
Summary
The facility failed to ensure staff adhered to the principles of antibiotic stewardship by not monitoring the appropriate use of antibiotics prescribed to residents, which is necessary to prevent antibiotic resistance and the spread of multidrug resistant organisms. The facility, with a census of 20 residents and a sample of 13, was unable to provide antibiotic and infection surveillance logs upon request. During an interview, the Infection Preventionist stated there were no electronic or paper records documenting the collection and analysis of data to track or monitor antibiotics ordered and laboratory reports received. Instead, the Infection Preventionist relied on daily review of the Electronic Medical Record for new antibiotic orders and provided only verbal reports of infections and antibiotic use at Quality Assurance meetings. The facility's policy required the Infection Preventionist to monitor every antibiotic ordered, complete antibiotic time-outs, summarize antibiotic use and resistance, and track outcome measures, but these actions were not documented or evidenced.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments in a timely manner for six residents, as required by regulation. Specifically, the MDS assessments for these residents were either completed or submitted late, with delays ranging from 9 to 52 days, and in one case, the assessment was still in progress and not completed or submitted as required. The issue was confirmed through review of electronic medical records and interviews with the facility's MDS Nurse and another administrative nurse, both of whom acknowledged that MDS assessments were in progress or completed late. The facility's own policy states a commitment to ensuring the accuracy, timeliness, and completeness of all MDS assessments, referencing the RAI manual.
Failure to Provide Written Discharge Notification and Complete Discharge Documentation
Penalty
Summary
The facility failed to provide a resident with a written notification of discharge and did not complete a recapitulation of the resident's stay as required. The resident, who had a history of frequent falls and cerebral infarction, was admitted with intact cognition and required maximal assistance with bathing and dressing, but was independent with ambulation. The resident's goal was to discharge back into the community, and an active discharge plan was documented. However, the electronic medical record lacked both a baseline and comprehensive care plan. Physician orders indicated discharge from physical therapy and a potential discharge home, and a progress note documented the resident leaving the facility with family members. Interviews with nursing staff revealed confusion and inconsistency regarding who was responsible for completing discharge paperwork. It was confirmed that the recapitulation of stay and discharge summary were not completed in the electronic medical record, and the facility did not provide or have the resident or responsible party sign any discharge paperwork. The facility's policy required informing residents or their representatives about discharge policies and documenting discharge planning and arrangements, but this was not followed in the resident's case.
Inaccurate MDS Documentation of Psychotropic Medication Administration
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for one resident, specifically regarding the documentation of psychotropic medications administered during the assessment lookback period. The resident in question had diagnoses of anxiety, depression, and insomnia, and was prescribed multiple psychotropic medications, including an antipsychotic (Abilify) and a hypnotic (trazodone). However, the MDS assessment did not record the administration of antipsychotic and hypnotic medications, despite evidence from the electronic medical record, care plan, and physician orders that these medications were given during the lookback period. Interviews with facility staff confirmed that the MDS should have indicated the use of antipsychotic and hypnotic medications, but this was not done. The facility's policy requires accuracy, timeliness, and completeness in all MDS assessments, referencing the RAI manual. The deficiency was identified through observation, record review, and staff interviews, which revealed the omission in the MDS documentation for the resident who was receiving several psychotropic medications as part of their treatment plan.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a Baseline Care Plan for a resident who was admitted with diagnoses of myocardial infarction and major depression. The resident's electronic medical record did not contain a Baseline Care Plan, despite facility policy requiring an initial person-centered care plan to be completed within 48 hours of admission. The omission was confirmed through record review and an interview with administrative staff, who stated that a baseline care plan assessment is expected upon admission. The lack of a Baseline Care Plan was identified during a review of the resident's records and was not in accordance with the facility's stated procedures for ensuring continuity of care and communication among staff.
Failure to Develop Comprehensive Care Plan for Resident with Cardiac and Mental Health Diagnoses
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident diagnosed with myocardial infarction and major depression. The resident's electronic medical record indicated a history of heart attack and persistent mood disorder, with an admission MDS showing intact cognition and documented behaviors such as rejection of care. Despite being independent in all activities of daily living, the resident's EMR did not contain a comprehensive care plan as required. Facility policy mandates an individualized, person-centered interdisciplinary plan of care for all residents, but this was not completed in a timely manner for the resident in question, as confirmed by administrative staff.
Care Plan Lacked Wound Care Interventions for Pressure Ulcer
Penalty
Summary
The facility failed to revise the care plan for a resident with a pressure ulcer. The resident's electronic medical record showed that the care plan, dated 08/17/23, did not include any wound care interventions, despite physician orders being in place to cleanse and dress open areas on the bilateral buttocks. The care plan only addressed cardiac complications and congestive heart failure, with interventions such as monitoring lung sounds, labored breathing, labs, vital signs, and signs of edema, but omitted any mention of wound care for the pressure ulcer. During the survey, a licensed nurse confirmed that the care plan lacked information regarding wound care for the resident. The resident was observed in her recliner and refused wound care observation. Administrative staff stated that care plans were expected to be completed in a timely manner. The facility's policy requires individualized, person-centered care plans based on the resident's needs, but this was not followed in the case of the resident with a pressure ulcer.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 18 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cimarron
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethel Home | 16.3 mi | ★★★★★ | 0 | 0 |
| Trinity Manor | 18.2 mi | ★★★★★ | 0 | 0 |
| Sunporch Of Dodge City | 18.4 mi | ★★★★★ | 1 | 0 |
| Kansas Soldiers Home | 18.5 mi | ★★★★★ | 5 | 0 |
| Manor Of The Plains | 18.8 mi | ★★★★★ | 12 | 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.