CMS · Kansas Department for Aging and Disability Services publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-03-20Record 175258-20260218-F584
F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-20Record 175258-20260218-F628
F637Assess the resident when there is a significant change in conditionScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-20Record 175258-20260218-F637
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-20Record 175258-20260218-F684
F730Observe each nurse aide's job performance and give regular training.Scope/severity FStandard
Staffing
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-03-20Record 175258-20260218-F730
F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-20Record 175258-20260218-F756
F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-20Record 175258-20260218-F757
F759Ensure medication error rates are not 5 percent or greater.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-03-20Record 175258-20260218-F759
F575Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 175258-20240403-F575
F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 175258-20240403-F582
F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 175258-20240403-F585
F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 175258-20240403-F623
F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 175258-20240403-F625
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 175258-20240403-F657
F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 175258-20240403-F676
F679Provide activities to meet all resident's needs.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 175258-20240403-F679
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 175258-20240403-F684
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 175258-20240403-F686
F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 175258-20240403-F688
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity EStandard
Care planningFalls
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 175258-20240403-F689
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 175258-20240403-F690
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 175258-20240403-F692
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-03Record 175258-20240403-F695
F700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 175258-20240403-F700
F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Scope/severity FStandard
Staffing
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 175258-20240403-F725
F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 175258-20240403-F726
F730Observe each nurse aide's job performance and give regular training.Scope/severity FStandard
Staffing
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 175258-20240403-F730
F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 175258-20240403-F756
F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 175258-20240403-F757
F758Implement 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 175258-20240403-F758
F760Ensure that residents are free from significant medication errors.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 175258-20240403-F760
F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 175258-20240403-F849
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 175258-20240403-F880
F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 175258-20240403-F883
F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 175258-20240403-F887
F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 175258-20240403-F925
F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Scope/severity FStandard
Staffing
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 175258-20240403-F947
F576Ensure residents have reasonable access to and privacy in their use of communication methods.Scope/severity CPaperwork
Dignity & rights
Widespread; potential for minimal harm.Corrected 2024-05-08Record 175258-20240403-F576
F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Scope/severity CPaperwork
Dignity & rights
Widespread; potential for minimal harm.Corrected 2024-05-08Record 175258-20240403-F577
F732Post nurse staffing information every day.Scope/severity CPaperwork
Staffing
Widespread; potential for minimal harm.Corrected 2024-05-08Record 175258-20240403-F732
F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-10-07Record 175258-20220906-F584
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-10-07Record 175258-20220906-F657
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-10-07Record 175258-20220906-F677
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-10-07Record 175258-20220906-F686
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-10-07Record 175258-20220906-F689
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-10-07Record 175258-20220906-F690
F693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-10-07Record 175258-20220906-F693
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-10-07Record 175258-20220906-F695
F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-10-07Record 175258-20220906-F757
F880Provide and implement an infection prevention and control program.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2022-10-07Record 175258-20220906-F880
F881Implement a program that monitors antibiotic use.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2022-10-07Record 175258-20220906-F881
F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2022-10-07Record 175258-20220906-F887
F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Scope/severity FStandard
Environment
Widespread; no actual harm, potential for more than minimal harm.Corrected 2022-10-07Record 175258-20220906-F921