Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Golden Rule Home during CMS and state inspections, most recent first.
The facility failed to ensure the food service director met minimum qualifications. The DM was not a CDM or CFSM and did not have an associate's degree or higher in food service management, while the RD was only at the facility one day per month. Records and interviews showed the DM had been in the role for about a year without the required credentials, and leadership was unaware of the missing certification.
Incorrect meal portion sizes were served instead of the planned menu portions. During lunch observation, the DM used a #16 dipper for mashed potatoes, pureed meat, and pureed green peas, and a #30 dipper for pureed bread, even though the menu called for a #12 dipper for pureed meatloaf and a #16 dipper for pureed bread. The DM confirmed the mismatch and stated the kitchen had always used the blue #16 dippers and did not have enough #12 dippers. The RD, DON, and ADM each stated they expected the kitchen to follow the approved menus.
QAPI Committee Lacked Medical Director Participation: The facility failed to ensure the Medical Director participated in QAPI Committee meetings as required. Review of 13 meeting sign-in sheets showed no documented attendance by the Medical Director, and the Administrator confirmed the MD did not attend or join by phone. The Administrator stated the MD was only in the facility on Wednesdays and meeting times did not always align with that availability.
Late and Missing Quarterly MDS Assessments: The facility failed to complete and submit quarterly MDS assessments on time for multiple residents, including residents with diagnoses such as HTN, DM2, depression, anxiety, osteoporosis, CHF, ESRD, and cerebral palsy. EMR review showed several assessments remained unsubmitted or were marked late, and the DON confirmed the quarterly MDSs were not completed timely after staffing changes left the facility without someone completing the assessments.
Smoking Safety and Supervision Failures: The facility did not complete or update smoking safety assessments correctly, allowed a resident on O2 to be in the smoking area without proper reassessment, did not assess another resident who smoked independently and kept cigarettes in the room, and failed to supervise an unsafe smoker as required by the smoking assessment. Staff interviews showed inconsistent awareness of who smoked, who needed supervision, and how smoking materials were controlled, while observations confirmed residents in the smoking area without staff oversight.
A resident with intact cognition and shortness of breath was allowed to self-administer ipratropium nebulizer treatments without a documented assessment or physician order permitting self-administration. The resident kept vials in the room and was observed using the nebulizer independently, while staff interviews confirmed the LPN gave the medication without checking the order, care plan, or assessment.
Failure to Timely Report Suspected Abuse: A CNA did not immediately report a suspected abuse allegation involving a resident with Alzheimer’s disease, anxiety, and major depressive disorder. Instead of notifying an on-duty supervisor or the Abuse Coordinator, the CNA texted the off-duty ADON, and the allegation was not reported to the SSA within the required timeframe. Staff interviews confirmed the Abuse Coordinator was not notified immediately, and the DON and Administrator acknowledged the delay.
Failure to document PRN inhaler administration in the MAR for a resident with dementia, anxiety, and respiratory failure. Staff notes showed the resident frequently requested the Ventolin HFA inhaler, and an ACMA, LPN, DON, and Administrator all stated PRN inhaler use should be documented, but the MAR did not reflect the administrations.
Improper nebulizer storage and failure to use EBP PPE: A resident with a PRN nebulizer order was observed multiple times with the mouthpiece left uncovered on the bedside table instead of stored in a bag or container as required by facility policy. In a separate event, staff provided wound care, transfers, and incontinence care for a resident with pressure wounds and moderate cognitive impairment without using gowns for EBP, and staff stated they were unfamiliar with EBP requirements.
The facility did not ensure that two residents were offered the right to formulate an advance directive, as required by their policy. The medical records lacked the necessary documentation, and the DON and SSD confirmed the absence of these forms.
The facility failed to update care plans quarterly for three residents, as required by their policy. Despite having significant medical diagnoses, the care plans lacked quarterly updates. The DON admitted that care plans were updated with new orders but not quarterly, relying on personal knowledge for evaluating interventions.
A resident with multiple diagnoses, including metabolic encephalopathy, was not given thorough weekly skin assessments as required. Despite physician orders, assessments were incomplete, with dressings on the resident's heels not being removed for proper evaluation. The facility failed to adhere to its protocol for skin assessments.
The facility failed to ensure dietary staff properly used hair nets, as observed with a cook who had hair outside the hairnet and a ponytail not secured. The Dietary Manager confirmed the policy required all hair to be secured, which was not followed in this instance.
The facility failed to provide adequate pressure ulcer care, as a resident was not consistently repositioned, and timely wound care orders were delayed. Another resident did not receive consistent weekly wound assessments, with missing documentation for June and July.
A facility failed to provide adequate hydration to a resident with hypotension and acute kidney failure. Records showed missed hydration opportunities over several months, and the ADON could not explain the missing entries despite hydration being scheduled three times daily.
Food Service Director Lacked Required Qualifications
Penalty
Summary
The facility failed to ensure that the designated director of food service met the minimum required qualifications. The facility did not employ a full-time Registered Dietitian, and the Dietary Manager was not a Certified Dietary Manager or Certified Food Service Manager and did not have an associate's degree or higher in food service management. The report states this affected 52 residents who received meals from the kitchen, out of a total census of 56. Facility records showed a Dietary Manager job description that required a bachelor's degree or related experience and indicated the position must hold or be capable of acquiring state-required certificates. Interviews revealed the Dietary Manager had been in the position for about a year, was not certified as a CDM, and did not have a Food Service Manager certificate at the time of the survey. The Dietary Manager confirmed she did not have a CDM or CFSM certification and did not have an associate's or higher degree in food service management or hospitality. The Registered Dietitian stated she was at the facility one day per month and was a contracted employee who did not keep employee records. The Executive Director and Assistant Director of Nursing were not aware that the Dietary Manager lacked the required certification, and the facility did not have a completed job description and orientation checklist for the Dietary Manager.
Incorrect meal portion sizes served instead of planned menu portions
Penalty
Summary
The facility failed to follow the planned, written menu for 1 of 2 meals observed when it served incorrect portion sizes for the lunch meal. The facility policy titled Menus, revised 10/2008, stated that menus shall meet the nutritional needs of residents, be prepared in advance, and be followed. The Menu Guide Report for the lunch meal on Tuesday 06/09/2026 specified 1/3 cup garlic mashed potatoes and 1/3 cup green peas for regular, pureed, and mechanical soft diets, and for pureed diets it also listed a #12 dipper of pureed meatloaf and a #16 dipper of pureed bread. During lunch observations beginning at 12:05 PM, the Dietary Manager served the mashed potatoes for all diets and the pureed meat and pureed green peas for pureed diets with a blue #16 dipper, and served the pureed bread with a black #30 dipper. In interview, the DM confirmed she used the #16 dipper for the mashed potatoes, pureed meat, and pureed green peas, and the #30 dipper for the pureed bread. She stated dietary staff should look in the menu book to know what size portion to serve, confirmed the correct portion should have been the #12 dipper, and stated they had always used the blue #16 dippers and did not have enough #12 dippers to serve that size portion. The RD stated she reviewed and approved the menus and expected kitchen staff to follow them or make appropriate substitutions, the DON stated she expected kitchen staff to follow the menus, and the ADM stated he expected the kitchen to follow the policy and procedures for following the menus.
QAPI Committee Lacked Medical Director Participation
Penalty
Summary
The facility failed to ensure the Medical Director participated in the Quality Assurance and Performance Improvement (QAPI) Committee meetings as required for 13 of 13 reviewed meetings held from 05/30/2025 through 05/29/2026. A facility policy titled Quality Assurance and Performance Improvement (QAPI) Committee, dated 04/2014, stated the QAPI Committee shall include the Medical Director as a member. Review of the QAPI meeting sign-in sheets for each of the 13 meetings showed no documented evidence that the Medical Director attended. During interviews on 06/12/2026, the Administrator reviewed the sign-in sheets and confirmed the Medical Director had not attended the meetings, stated the Medical Director was in the facility on Wednesdays but the meetings did not always occur on Wednesdays, and stated the Medical Director's availability was limited. The Administrator also stated the Medical Director did not participate by phone and suggested the facility may need to hold QAPI meetings at times when the Medical Director was in the facility.
Late and Missing Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were completed on a quarterly basis and submitted within the required timeframe for 17 of 18 residents reviewed for resident assessments. Facility policy titled, Resident Assessment Instrument, stated the Assessment Coordinator was responsible for ensuring the Interdisciplinary Assessment Team conducted timely resident assessments and reviews at least quarterly. State Operations Manual guidance cited in the report stated a quarterly assessment is timely when the ARD is within 92 days of the previous OBRA assessment and the MDS completion date is no later than 14 days after the ARD. Record review showed multiple residents had quarterly MDS assessments that were overdue, not completed, or not submitted to CMS by the time of survey. Several residents had quarterly assessments with created dates of 05/15/2026 that remained incomplete and unsubmitted as of 06/10/2026, with EMR symbols showing a triangle/exclamation mark and no thumbs-up symbol to indicate CMS acceptance. Examples included residents with diagnoses such as hypertension, diabetes, depression, anxiety disorder, osteoporosis, heart failure, kidney failure, end stage renal disease, cerebral palsy, severe intellectual disability, and gastroesophageal reflux. For some residents, the most recent accepted assessment was an admission, quarterly, or significant change assessment completed months earlier, and the next quarterly assessment was due before the late or missing assessment was completed. The report also identified residents whose quarterly assessments were not completed after a significant change or after discharge. One resident had a significant change MDS as the most recent assessment, while another resident had been discharged and no discharge MDS was completed. During interview, the DON stated the EMR symbols indicated whether assessments were accepted by CMS or submitted late, and she confirmed the quarterly MDS assessments for the listed residents were not completed and submitted timely. She stated she had started catching up on overdue assessments after beginning employment because no one had been completing MDS assessments after the former DON left. The Administrator stated the facility had a lapse in completing MDS assessments because the person completing them left, and his expectation was for staff to follow policy and procedure.
Smoking Safety Assessments and Supervision Failures
Penalty
Summary
The facility failed to assess smoking safety before allowing residents to smoke unsupervised, failed to supervise a resident who had been identified as needing supervision with smoking, and failed to ensure residents smoked in accordance with the facility’s smoking policy. The report identified these failures for three residents reviewed for smoking and stated the practices had the potential to affect 14 residents who smoked. The facility policy required a safe smoking assessment upon or prior to admission, re-evaluation with a change in condition, no smoking with oxygen in use or oxygen cylinders in the smoking area, and supervision for residents determined to be unsafe smokers. Resident #68 was admitted with diagnoses including polyneuropathy, dependence on supplemental oxygen, obstructive pulmonary disease, and type 2 diabetes mellitus. The resident’s admission MDS showed intact cognition, no upper-extremity range-of-motion limitations, current tobacco use, and oxygen therapy. The safe smoking assessment completed on admission had all Yes responses, but the form was not marked to indicate safe or unsafe smoker and was not signed by an IDT member. Later, nursing notes documented that the resident was in the smoking area with oxygen on, including one note stating the resident was removed from the area and educated, and another noting the SSD was notified that the resident was noncompliant with removing oxygen when outside smoking. Staff interviews showed the resident had been seen in the smoking area with a portable oxygen tank, that the oxygen was functioning at the time, and that staff had not reassessed the resident for safe smoking. The resident stated they went to the smoking area every two to three hours, sometimes to smoke and sometimes just to sit, kept their own smoking materials, and had no supervision when smoking. Resident #50’s admission record and MDS showed diagnoses of gout, rheumatoid arthritis, and heart failure, with intact cognition. The smoking assessment for this resident was undated, had a handwritten note indicating the resident was a non-smoker, and had no Yes or No responses checked and no IDT signature. The care plan did not address smoking. Despite this, the resident stated they smoked independently and kept smoking supplies in their room, and staff later observed the resident outside smoking with other residents and no staff present. Resident #55’s quarterly MDS showed intact cognition, and a prior smoking assessment identified the resident as an unsafe smoker because the resident could not light and smoke a cigarette while demonstrating safe technique for putting out matches or a lighter and disposing of ash. The care plan noted the resident liked to smoke and go outside to the smoking area, but staff interviews showed they were not aware of any residents who required supervision with smoking. The resident was observed outside in the smoking area, and nursing staff stated there was no system to communicate who required supervision, while the DON stated that if an assessment indicated a resident should be supervised, she would expect them to be supervised.
Failure to Assess and Order Self-Administration of Nebulizer Medication
Penalty
Summary
The facility failed to ensure that Resident #33 was assessed for the ability to safely self-administer medication and failed to obtain a physician's order before allowing the resident to self-administer ipratropium bromide nebulizer treatments. The resident was admitted with diagnoses including essential hypertension and polyneuropathy, and a quarterly MDS showed a BIMS score of 15, indicating intact cognition. The resident also had shortness of breath with exertion, and the physician's orders included ipratropium bromide 0.02% one vial via nebulizer three times a day as needed, but there was no order allowing self-administration or keeping medications at bedside. The care plan identified the resident as at risk for shortness of breath and directed staff to administer medications as ordered, including ipratropium as ordered by the physician. There was no care plan evidence that the resident could self-administer medications. During observation, the resident was seen in the room with a nebulizer machine and stated they normally self-administered the treatment as needed and kept the nebulizing medication in the room. The resident was observed actively self-administering the nebulizer treatment and showed four vials of ipratropium bromide in a bedside drawer, stating an LPN had given the solution for self-administration. Staff interviews confirmed there was no assessment or physician's order for self-administration. One LPN stated the resident had not been assessed and did not have an order to self-administer, while another LPN said he believed the resident had been assessed and had given the resident one vial to self-administer without checking the physician's orders, care plan, or assessment. The NP, pharmacist, previous DON, and DON all stated that residents should not self-administer medications without an assessment and physician's order, and that medications should not be left at the bedside without that authorization.
Failure to Timely Report Suspected Abuse
Penalty
Summary
The facility failed to ensure a CNA immediately reported a suspected abuse allegation in accordance with the facility’s abuse policy for Resident #20. The policy stated that when abuse, neglect, mistreatment, or misappropriation of personal property is observed or suspected, staff must immediately notify their supervisor on duty, who then notifies the abuse coordinator, administrator, and DON. Instead, CNA #11 sent a text message to the off-duty ADON about an incident that made her uncomfortable, rather than reporting directly to an on-duty supervisor or the Abuse Coordinator. Resident #20 was admitted with diagnoses including Alzheimer’s disease, anxiety disorder, and major depressive disorder. On the evening of the incident, a nurse observed a CNA sitting at eye level and talking with the resident. The nurse documented that the resident slapped the CNA on the face, the CNA raised his hands as if to block another slap, and the nurse then stepped in to monitor the resident. The nurse also documented that the resident removed items from the desk and medication cart and had two small actively bleeding skin tears on the back of the left hand. Text message correspondence showed CNA #11 contacted the ADON at 5:54 PM to report that something happened that bothered her, but the message did not identify who or what was involved at first. The ADON was not in the building at the time and stated she later learned of the allegation the next day. The facility submitted the initial report to the SSA the following day at 1:29 PM, and the SSD, who was the Abuse Coordinator, stated she was not notified until mid-morning the next day. The DON and Administrator both acknowledged that the allegation was not reported to the Abuse Coordinator within the required two-hour timeframe.
Failure to Document PRN Inhaler Administration
Penalty
Summary
Medication administration was not accurately documented in the medical record for one resident who had diagnoses including dementia, anxiety, and respiratory failure and a BIMS score of 9 indicating moderate cognitive impairment. The resident had an order for Ventolin HFA, 2 puffs every 4 hours as needed for shortness of breath and wheezing. The resident’s records showed a PRN inhaler dose documented on one date in January 2025, but there was no documentation that the inhaler was administered on any other January date, and the February 2025 MAR did not show any Ventolin HFA or other inhaled medication administrations during that month. Nurse’s notes reflected that the resident requested the PRN inhaler and, on one occasion, was given the inhaler but refused to return it to the nurse. Another note documented the resident requesting an as-needed breathing treatment and becoming upset when staff would not allow extra doses of medication. During interviews, an ACMA stated PRN inhaler administrations should be initialed on the MAR and documented on the PRN medication sheet, and another ACMA stated he documented PRN medications after administration but had forgotten to do so at times and remembered the resident requesting the inhaler frequently. The LPN, DON, and Administrator each stated that PRN inhaler or medication administrations should be documented in the MAR.
Improper Nebulizer Storage and Failure to Use EBP PPE
Penalty
Summary
The facility failed to ensure proper storage of respiratory equipment for a resident who had an order for ipratropium bromide via nebulizer three times a day as needed. The resident had diagnoses including essential hypertension and polyneuropathy, and a quarterly MDS showed a BIMS score of 15, indicating intact cognition. During multiple observations, the resident was seen self-administering a nebulizer treatment while the nebulizer machine sat on the bedside table with the medication chamber and mouthpiece attached and the mouthpiece lying directly on the table without a bag or cover. Facility policy for administering medications through a small volume nebulizer stated that after treatment the equipment should be rinsed, disinfected, dried, and then stored in a plastic bag with the resident’s name and date. A facility document for oxygen and respiratory customers also stated that nebulizer circuits should be stored in a plastic bag labeled with the patient’s name and date, and that miscellaneous disposable equipment should be covered when not in use. Staff interviews confirmed that the mouthpiece should be cleaned, dried, and stored in a bag when not in use, and several staff members observed the mouthpiece sitting uncovered on the bedside table and acknowledged it should have been bagged. The facility also failed to ensure staff used PPE during care of a resident on Enhanced Barrier Precautions. The resident had a BIMS score of 10, indicating moderate cognitive impairment, and had a Stage 4 pressure ulcer present on admission as well as two pressure wounds to the buttocks on the care plan. During an observation of wound measurement and treatment, there was no EBP sign on the door and no PPE beside the door or inside the room. LPN and CNA staff transferred the resident, removed clothing and a brief, and prepared the resident for wound measurements and treatment without donning gowns. The wound physician and wound NP wore gowns and gloves during the wound treatment, and afterward an LPN completed wound care while wearing a disposable gown. CNA staff then provided incontinence care and transferred the resident back to the wheelchair without gowns. CNA staff stated they had not been educated on EBP and did not know they should have worn gowns, and an LPN stated he was not sure what EBP stood for. The DON stated the facility had not been practicing EBP and that signage should be on the door to notify staff that the resident needed EBP.
Failure to Offer Advance Directives
Penalty
Summary
The facility failed to ensure that residents were offered the right to formulate an advance directive, as required by their policy. This deficiency was identified for two of the three sampled residents reviewed for advance directives. The facility's policy, dated April 2008, mandates that upon admission, the Social Services Director or designee should provide written information to residents about their right to make medical decisions and formulate advance directives. However, the medical records for two residents did not contain an advance directive or an acknowledgement form. During an interview, the Director of Nursing (DON) was unable to locate these documents in the residents' charts, and the Social Services Director (SSD) confirmed that the forms were not present for the two residents.
Failure to Update Care Plans Quarterly
Penalty
Summary
The facility failed to ensure that care plans were updated quarterly for three residents, as required by their Care Plans policy. The policy, dated October 2010, mandates that care plans include measurable objectives and timetables to meet residents' needs and be reviewed and updated at least quarterly by the Care Planning/Interdisciplinary Team. However, the care plans for three residents, each with significant medical diagnoses, lacked these quarterly updates. Resident #14, diagnosed with depression and anxiety, had a care plan dated December 11, 2023, but no quarterly updates were recorded. Similarly, Resident #26, with acute kidney failure, cerebral infarction, bipolar disorder, COPD, and hypertension, had a care plan dated November 20, 2023, without quarterly updates, despite having comprehensive assessments in May and August 2024. Resident #27, diagnosed with neuralgia, ALS, and major depressive disorder, had a care plan dated March 6, 2024, but no quarterly updates, even though comprehensive assessments were conducted in June and September 2024. During an interview on October 2, 2024, the Director of Nursing (DON) acknowledged that care plans were updated with each new order but admitted that quarterly updates were not conducted. The DON stated that quarterly MDS assessments were performed, but care plan updates were only done annually. When asked about evaluating the effectiveness of interventions, the DON responded that they relied on personal knowledge rather than formal evaluations. This lack of adherence to the facility's policy resulted in the failure to conduct quarterly updates for the care plans of the three residents, as required.
Failure to Conduct Comprehensive Weekly Skin Assessments
Penalty
Summary
The facility failed to conduct thorough weekly skin assessments for a resident with non-pressure related skin conditions. The resident, who was admitted with diagnoses including metabolic encephalopathy, neuropathy, and gout, had a physician order for weekly skin assessments on Mondays. However, documentation showed that the resident refused a skin assessment on two occasions, and the assessments that were conducted did not include the removal of dressings to properly assess the skin underneath. On one occasion, the LPN documented a head-to-toe skin assessment but failed to note the presence of dressings on the resident's heels. Observations revealed that the resident had adhesive foam dressings on their heels, which had been placed by the hospital prior to their arrival at the facility. The dressings were dated several weeks prior, and the facility had not addressed them. The ADON stated that skin assessments should include the removal of dressings to assess the skin beneath, which was not done in this case. The deficiency was identified as a failure to perform comprehensive skin assessments as per the facility's protocol and physician orders.
Improper Use of Hair Nets by Dietary Staff
Penalty
Summary
The facility failed to ensure proper use of hair nets by dietary staff, specifically Cook #1, during kitchen sanitation. On the morning of September 30, 2024, Cook #1 was observed preparing the noon meal with hair outside of their hairnet around the ears and a ponytail not secured within the hairnet. When questioned, the Dietary Manager (DM) confirmed that the policy required all hair to be secured in a hairnet and acknowledged that Cook #1's hair was not fully contained as per the policy. This observation was made in a facility housing 34 residents.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for residents, as evidenced by several deficiencies. A resident admitted with multiple wounds was not consistently repositioned according to the facility's policy, which requires repositioning at least every two hours. Documentation of repositioning was missing for several periods, and the resident was not repositioned for extended hours on multiple occasions. Additionally, the facility did not obtain timely orders for wound care upon the resident's admission, with a delay in consulting a wound care specialist. Another resident with a stage four pressure ulcer did not receive consistent weekly wound assessments as required by the facility's policy. The documentation for June and July was incomplete, with missing measurements and observations of the pressure ulcer. The Director of Nursing acknowledged that the required skin assessments were not completed during these months.
Failure to Provide Adequate Hydration
Penalty
Summary
The facility failed to provide adequate hydration to a resident, identified as Res #2, who was admitted with diagnoses including hypotension and acute kidney failure. A review of meal percentage records and intake and output records revealed that the resident did not receive hydration on 13 out of 69 opportunities in May 2024, 2 out of 90 opportunities in June 2024, and 7 out of 51 opportunities in July 2024. The Assistant Director of Nursing (ADON) confirmed that hydration and ice are supposed to be provided to residents three times per day, once on each shift, but was unable to explain the missing entries on the resident's hydration records.
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Illustrative
What surveyors actually found near you
We read the 16 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
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Illustrative
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Nursing homes near Shawnee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Skilled Nursing And Therapy | 3.5 mi | ★★★★★ | 0 | 0 |
| Shawnee Colonial Estates Nursing Home | 4.1 mi | ★★★★★ | 0 | 0 |
| Shawnee Care Center | 4.5 mi | ★★★★★ | 7 | 0 |
| The Regency Skilled Nursing And Therapy | 5.2 mi | ★★★★★ | 0 | 0 |
| Mcloud Nursing Center | 11 mi | ★★★★★ | 2 | 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 October 2026) and official state health department websites.