Cycle 1
Health 2024-08-14 · Fire 2024-08-14
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Lindsborg, KS
Bethany Home Association
4-star overall rating with 3-star inspections with $8,326 in total fines with 7 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
321 N Chestnut Street, Lindsborg, KS
(785) 227-2334
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
85
Certified beds
Average residents
75
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2008-09-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.74
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
3.64
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
5.13
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.23
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.91
CMS adjusted RN staffing hours
Adjusted total hours
6.37
CMS adjusted total nurse staffing hours
Case-mix index
1.10
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
104
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
85.41
Composite VBP score used to determine payment impact.
Payment multiplier
1.0268
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
7.08
Baseline 44.00% · Performance 34.74% · Measure score 7.08 · Achievement 7.08 · Improvement 4.34
Adjusted total nurse staffing
10
Baseline 5.82 hours · Performance 6.49 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.8% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 38 · Observed rate 2.63% · Lower 95% interval 5.78% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 26 · Denominator 26 |
| Falls with major injury | 3.85% |
0.77%
3.1 pts worse
|
Numerator 1 · Denominator 26 |
| Discharge self-care score | 13.64% |
53.69%
40 pts worse
|
Numerator 3 · Denominator 22 |
| Discharge mobility score | 22.73% |
50.94%
28.2 pts worse
|
Numerator 5 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 3.85% |
2.29%
1.6 pts worse
|
Numerator 1 · Denominator 26 · Adjusted rate 4.26% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 6.6% |
8.2%
1.6 pts worse
|
Numerator 14 · Denominator 212 |
| Staff flu vaccination coverage | 21.72% |
42%
20.3 pts worse
|
Numerator 48 · Denominator 221 |
| Discharge function score | 18.18% |
56.45%
38.3 pts worse
|
Numerator 4 · Denominator 22 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.8
0.9 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.8 |
2.2
1.6 pts worse
|
1.8
2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.8 · Observed 2.8 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.8%
8.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.5%
4.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.7% |
4.4%
0.7 pts better
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 2.8% · Q3 3.0% · Q4 5.8% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.6%
5.6 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.6% |
5.0%
1.4 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 1.7% · Q3 1.8% · Q4 5.7% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.7% |
23.2%
6.5 pts better
|
19.6%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.3% · Q2 15.3% · Q3 16.1% · Q4 16.1% · 4Q avg 16.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.0% |
19.8%
12.8 pts better
|
16.7%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 6.4% · Q3 5.1% · Q4 9.3% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.3% |
18.4%
2.1 pts better
|
16.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 16.7% · Q3 15.6% · Q4 24.4% · 4Q avg 16.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.4% |
18.8%
7.4 pts better
|
14.9%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 8.6% · Q3 9.4% · Q4 15.1% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 10.2% |
1.8%
8.4 pts worse
|
1.0%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 9.4% · Q3 9.2% · Q4 14.7% · 4Q avg 10.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.5% |
3.1%
1.4 pts worse
|
1.7%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 2.9% · Q3 3.0% · Q4 7.6% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.4% |
23.2%
9.8 pts better
|
19.8%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 15.0% · Q3 13.6% · Q4 17.8% · 4Q avg 13.4% |
| Percentage of long-stay residents with pressure ulcers | 7.3% |
4.6%
2.7 pts worse
|
5.1%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 10.0% · Q3 4.2% · Q4 5.8% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
75.6%
24.4 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
73.5%
26.5 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-15 · Fire 2023-03-15
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2021-08-18 · Fire 2021-08-18
8 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
20 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-14
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-08-14
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-08-14
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-08-14
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-08-14
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-08-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-08-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-08-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-08-14
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-08-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-08-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-08-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-08-14
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-08-14
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-08-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-08-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-11
F · Potential for more than minimal harm
2023-03-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-04
F · Potential for more than minimal harm
2023-03-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-05-04
F · Potential for more than minimal harm
2023-03-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-05-04
F · Potential for more than minimal harm
2023-03-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-04
F · Potential for more than minimal harm
2023-03-15
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-05-04
F · Potential for more than minimal harm
2023-03-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-04
F · Potential for more than minimal harm
2023-03-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-04
E · Potential for more than minimal harm
2023-03-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-04
E · Potential for more than minimal harm
2023-03-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-04
E · Potential for more than minimal harm
2023-03-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-04
E · Potential for more than minimal harm
2023-03-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-05-04
D · Potential for more than minimal harm
2023-03-15
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-05-04
F · Potential for more than minimal harm
2021-08-18
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2021-11-04
F · Potential for more than minimal harm
2021-08-18
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2021-11-04
F · Potential for more than minimal harm
2021-08-18
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2021-11-04
F · Potential for more than minimal harm
2021-08-18
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2021-11-04
F · Potential for more than minimal harm
2021-08-18
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2021-11-04
F · Potential for more than minimal harm
2021-08-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-11-04
F · Potential for more than minimal harm
2021-08-18
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2021-11-04
F · Potential for more than minimal harm
2021-08-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-11-04
F · Potential for more than minimal harm
2021-08-18
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2021-11-04
F · Potential for more than minimal harm
2021-08-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-11-04
F · Potential for more than minimal harm
2021-08-18
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2021-11-04
F · Potential for more than minimal harm
2021-08-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-11-04
F · Potential for more than minimal harm
2021-08-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-11-04
F · Potential for more than minimal harm
2021-08-18
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-11-04
F · Potential for more than minimal harm
2021-08-18
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-09-29
F · Potential for more than minimal harm
2021-08-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-11-04
F · Potential for more than minimal harm
2021-08-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-11-04
F · Potential for more than minimal harm
2021-08-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-11-04
D · Potential for more than minimal harm
2021-08-18
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-11-04
D · Potential for more than minimal harm
2021-08-18
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2021-11-04
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-02
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-09-02
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-09-17
F · Potential for more than minimal harm
2025-06-25
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-07-07
F · Potential for more than minimal harm
2024-08-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-08-14
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-08-14
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-08-14
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-09-06
D · Potential for more than minimal harm
2023-08-31
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-09-15
J · Immediate jeopardy
2023-06-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-16
F · Potential for more than minimal harm
2023-03-15
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-04-28
E · Potential for more than minimal harm
2023-03-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-15
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-15
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-15
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-04-28
C · Minimal harm
2023-03-15
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-04-28
F · Potential for more than minimal harm
2021-08-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-09-01
E · Potential for more than minimal harm
2021-08-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-09-01
D · Potential for more than minimal harm
2021-08-18
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-09-01
D · Potential for more than minimal harm
2021-08-18
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-09-01
D · Potential for more than minimal harm
2021-08-18
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-09-01
D · Potential for more than minimal harm
2021-08-18
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2021-09-01
Penalties and ownership
What sits behind the stars
$8,326
2023-06-21
Fine
Fine · fine $8,326
Fine
Ownership
Brumbaugh, Melissa
Corporate Officer · Individual
Carlson, Karen
Corporate Director · Individual
Cummings, Ken
Corporate Director · Individual
Erickson, Kriston
Operational/Managerial Control · Individual
Erickson, Kriston
Corporate Officer · Individual
Swenson, Galen
Corporate Director · Individual
Truhe, Amy
Corporate Director · Individual
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