THE SHEPHERD'S CENTER
Non profit - Corporation
28 Beds
Independent
Data: November 2025
3 Immediate Jeopardy citations
Trust Grade
7/100
Photo by Cimarron
Last Inspection: February 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
The Shepherd's Center in Cimarron, Kansas has received a Trust Grade of F, indicating significant concerns about the quality of care provided. It ranks at the bottom of all facilities in the state and county, meaning there are no other options available that are better. The facility is new and has not shown any trend of improvement, as this is its first inspection. Staffing is a positive aspect, with a turnover rate of 0%, which is well below the state average, and the facility benefits from more registered nurse coverage than 98% of other facilities in Kansas. However, the facility has received concerning fines totaling $13,627, which is higher than 75% of Kansas facilities, reflecting compliance issues. Serious incidents include a staff member coercing a resident into writing a check for $300, which the facility failed to report, placing residents at risk for further exploitation. Overall, there are critical issues that families should carefully consider.
- Trust Score
- F
- In Kansas
- #112/223
- Safety Record
- High Risk
- Inspections
- Too New
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ⚠ Watch
- $13,627 in fines. Higher than 90% of Kansas facilities, suggesting repeated compliance issues.
- Skilled Nurses ✓ Good
- Each resident gets 86 minutes of Registered Nurse (RN) attention daily — more than 97% of Kansas nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 13 deficiencies on record. Higher than average. Multiple issues found across inspections.
7/100
Top 50%
Review needed
0 → 13 violations
☆☆☆☆☆
0.0
Overall Rating
☆☆☆☆☆
0.0
Staff Levels
☆☆☆☆☆
0.0
Care Quality
☆☆☆☆☆
0.0
Inspection Score
↔
Stable
: 0 issues
2024: 13 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
Federal Fines: $13,627
Below median ($33,413)
Minor penalties assessed
The Ugly 13 deficiencies on record
3 life-threatening
Jun 2024
3 deficiencies
3 IJ (2 facility-wide)
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0602
(Tag F0602)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 25 residents. The sample included six residents reviewed for misappropriation and exploitation...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 25 residents. The sample included six residents reviewed for misappropriation and exploitation. Based on interview and record review, the facility failed to ensure Resident (R)1 remained free from misappropriation of funds, when Housekeeping Staff D coerced the resident to write her a check for $300.00. This deficient practice placed R1and other residents of the facility in immediate jeopardy with the risk for a negative psychosocial impact in safety and security.
Findings included:
- R1's Electronic Health Record (EHR) revealed diagnoses that included interstitial pulmonary disease (a disorder that causes progressive scarring of lung tissue), major depressive disorder (a major mood disorder which causes persistent feelings of sadness), and anxiety disorder (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).
The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 was independent with all cares.
The Quarterly MDS dated 06/14/24, documented a BIMS score of 15, which indicated intact cognition. R1 was independent with all cares.
Review of witness statements revealed the following:
On 06/27/24, untimed, R1 documented that on 05/22/24 at unknown time, Housekeeping Staff D came into her room and asked for $500.00 with the promise to repay her the next day. R1 stated that she could not loan out that much money. On 05/23/24, Housekeeping Staff D returned to R1's room and requested a smaller loan of $300. R1 stated she was in pain from a recent fall and just wanted Housekeeping Staff D to leave her room, so she wrote a check for $300.00.
Undated and untimed witness statement revealed Administrative Staff A documented on 05/27/24 at 01:38 PM, Administrative Nurse B notified her that Housekeeping Staff D requested $300.00 from R1 and that R1 wrote Housekeeping Staff D a check. Administrative Staff A documented she gave the directive to terminate Housekeeping Staff D effective immediately. Administrative Staff A then notified R1's family of the events, that Housekeeping Staff D was terminated, and the lost funds would be refunded to the resident. Administrative Staff A documented that two termination letters were sent to Housekeeping Staff D's last known address via certified mail, which were returned as undeliverable. Administrative Staff A further documented she held a staff meeting with the department managers and directed them to hold individual department meetings to advise the staff of what had happened and to reinforce the ANE training, specific to taking money from residents.
Undated and untimed witness statement revealed Administrative Nurse B documented that on 05/27/24 at 01:32 PM, Administrative Staff L notified her of a possible exploitation of R1 and was going to confirm with R1. On 05/27/24 at 01:38 PM, Administrative Nurse B notified Administrative Staff A and Housekeeping Staff J. On 05/27/24 at 01:52 PM, a video call was completed between Administrative Nurse B with Administrative Staff L and R1 and R1 confirmed that she had written a check to Housekeeping Staff D and that it had been cashed. R1 further stated that when Housekeeping Staff D asked for the money, she was in pain from a recent fall and had given her a check for the $300.00 so Housekeeping Staff D would leave her alone. On 05/27/24 at 02:03 PM, Administrative Nurse B notified R1's family. On 05/28/24 at unknown time, Administrative Nurse B documented that Administrative Staff A spoke with R1's family who stated that he did not want the police involved since Housekeeping Staff D had been fired and the monies were refunded to R1.
On 06/27/24 and untimed revealed Administrative Staff L documented that on 05/27/24, she was informed that an unknown staff member had asked a resident for money. Administrative Staff L documented that she questioned R1 if it was true and R1 said yes. Administrative Staff L called Administrative Nurse B while in R1's room and completed a video call with R1.
An undated and untimed witness statement of Housekeeping Staff J documented that on 05/24/24, Housekeeping Staff D and Housekeeping Staff J discussed one resident stating Housekeeping Staff D asked him for 300.00 dollars. Housekeeping Staff J documented that she had a teachable moment with Housekeeping Staff D, that staff should not even joke or even discuss things in front of residents, that she could get in trouble.
On 06/27/24 and untimed, Housekeeping Staff J documented that on 05/27/24, Administrative Nurse B called her around 01:30 PM to ask her if she had heard that R1 was asked for money from Housekeeping Staff D. Housekeeping staff J documented she told Administrative Nurse B no. Housekeeping Staff J documented that on 05/28/24 she contacted Housekeeping Staff D and asked her to come to the facility to see her. Housekeeping Staff D replied at 02:25 PM, she was not able to come in. Housekeeping Staff J was unable to contact Housekeeping Staff D after that time.
On 06/26/24 at 03:12 PM, R1 stated Housekeeping Staff D borrowed $300 from her in the last 2-3 weeks and that Housekeeping Staff D stated that she would repay the loan the next day, but she never came back to the facility. She felt exploited due to the housekeeper repeatedly asking for money and she would not take no for an answer, so R1 finally wrote the housekeeper a check so she would just leave her alone. R1 reported the housekeeper no longer worked at the facility. The facility offered to reimburse her for the lost funds from her (Housekeeping Staff D's) last paycheck.
On 06/27/24 at 11:22 AM, R2 reported Housekeeping Staff D stated she wanted someone to give her $300.00 and would point at other residents walking by R2's room and ask R2 if she thought that they (the other residents) would give her money. R2 revealed that she told Housekeeping Staff D that she had no money and to not ask her again.
On 06/26/24 at 04:30 PM, Certified Medication Aide (CMA) E stated she would notify Administrative Staff A or Administrative Nurse B right away if she suspected, heard, or witnessed any type of abuse, neglect, and exploitation.
On 06/26/24 at 04:40 PM, Certified Nurse Aide (CNA) F, CNA G, CNA H revealed they all had abuse, neglect and exploitation (ANE) training last October (2023), and in April 2024, with an online learning module. They all revealed that they had not received recent ANE training of any type since April 2024.
On 06/26/24 at 04:43 PM, Dietary K stated the last time she had received ANE training was in April of 2024.
On 06/26/24 at 04:48 PM, Licensed Nurse (LN) C revealed she had her last ANE training via an on-line learning module in April 2024.
On 06/26/24 at 04:50 PM, Administrative Nurse B revealed that her expectation was for staff to notify the Director of Nurses, social services, or the Administrator if there were allegations and then the proper notifications could be done. Additionally stated that staff were educated, however as of 06/27/24 at 09:00 AM, the facility failed to produce documentation of staff training after the incident.
On 06/26/24 at 03:50 PM, Administrative staff A confirmed the above information and stated that she did not notify law enforcement or the State Agency of the exploitation of the resident. She confirmed that they did terminate the offending employee and initiated reimbursement to the resident for the lost funds and stated that no solicitation and no gratuities were covered in the employee handbook which documented that solicitation of or by employees was prohibited.
The facility's undated Abuse, Neglect and Exploitation policy documented that the facility would prohibit and prevent exploitation of residents and misappropriation of resident property. Further, defined exploitation as the unfair treatment or taking advantage of a resident for personal gain through the use of manipulation, intimidation or coercion. The facility would comply with the seven-step approach to detection and prevention. If an allegation is made, notification would make a report with local law enforcement agency and the State Agency, as required.
The facility failed to ensure R1 remained free from misappropriation of funds, when housekeeping staff D exploited the resident of $300.00. R1 stated she felt coerced into providing housekeeping staff D as she would not leave the resident alone until the check was written. This deficient practice placed R1 other residents in the facility in immediate jeopardy with the risk for a negative psychosocial impact in safety and security.
On 06/27/24 at 10:10 AM, Administrative Staff A was provided the Immediate Jeopardy (IJ) template for failure to prevent exploitation of the residents, which placed them in immediate jeopardy.
The facility submitted an acceptable plan for removal of the immediate jeopardy on 06/27/24 at 01:33 PM which included the following:
1. On 06/27/24 at 10:52 AM, all staff would receive either group or individual ANE training with a member of management.
2. On 06/27/24 at 10:52 AM, all staff were notified by the facility's communication app that prior to returning to work, staff must receive ANE training with a member of management.
3. On 06/27/24 at 10:52 AM, the facility's Medical Director and R1's primary care provider (PCP) was notified about the alleged exploitation of R1.
4. On 06/27/24 at 10:52 AM, the Long-Term State Ombudsman was notified about the alleged exploitation of R1.
5. On 06/27/24 at 11:30 AM an ad-hoc QAPI (quality assurance, process improvement) meeting was held.
The survey team validated the immediate jeopardy was removed on 06/27/24 at 01:40 PM, following the facility's implementation of the plan for removal of the immediate jeopardy.
The deficient practice remained at a scope and severity level of a G following the removal of the immediate jeopardy.
CRITICAL
(L)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Report Alleged Abuse
(Tag F0609)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 25 residents. The sample included six residents reviewed for misappropriation and exploitation...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 25 residents. The sample included six residents reviewed for misappropriation and exploitation. Based on interview and record review, the facility failed to ensure the timely reporting of alleged exploitation to the State Agency (SA- a state governmental agency that provides oversight for the Centers for Medicare & Medicaid Services [CMS - the federal government agency that administers the nation's major healthcare programs]) or local law enforcement, as required, when the facility failed to report the allegation of exploitation of Resident (R) when Housekeeping Staff D coerced the resident to write her a check for $300.00. This deficient practice placed R1and other residents of the facility in immediate jeopardy with the risk for a negative psychosocial impact in safety and security.
Findings included:
- R1's Electronic Health Record (EHR) revealed diagnoses that included interstitial pulmonary disease (a disorder that causes progressive scarring of lung tissue), major depressive disorder (a major mood disorder which causes persistent feelings of sadness), and anxiety disorder (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).
The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 was independent with all cares.
The Quarterly MDS dated 06/14/24, documented a BIMS score of 15, which indicated intact cognition. R1 was independent with all cares.
Review of witness statements revealed the following:
On 06/27/24, untimed, R1 documented that on 05/22/24 at unknown time, Housekeeping Staff D came into her room and asked for $500.00 with the promise to repay her the next day. R1 stated that she could not loan out that much money. On 05/23/24, Housekeeping Staff D returned to R1's room and requested a smaller loan of $300. R1 stated she was in pain from a recent fall and just wanted Housekeeping Staff D to leave her room, so she wrote a check for $300.00.
Undated and untimed witness statement revealed Administrative Staff A documented on 05/27/24 at 01:38 PM, Administrative Nurse B notified her that Housekeeping Staff D requested $300.00 from R1 and that R1 wrote Housekeeping Staff D a check. Administrative Staff A documented she gave the directive to terminate Housekeeping Staff D effective immediately. Administrative Staff A then notified R1's family of the events, that Housekeeping Staff D was terminated, and the lost funds would be refunded to the resident. Administrative Staff A documented that two termination letters were sent to Housekeeping Staff D's last known address via certified mail, which were returned as undeliverable. Administrative Staff A further documented she held a staff meeting with the department managers and directed them to hold individual department meetings to advise the staff of what had happened and to reinforce the ANE training, specific to taking money from residents.
Undated and untimed witness statement revealed Administrative Nurse B documented that on 05/27/24 at 01:32 PM, Administrative Staff L notified her of a possible exploitation of R1 and was going to confirm with R1. On 05/27/24 at 01:38 PM, Administrative Nurse B notified Administrative Staff A and Housekeeping Staff J. On 05/27/24 at 01:52 PM, a video call was completed between Administrative Nurse B with Administrative Staff L and R1 and R1 confirmed that she had written a check to Housekeeping Staff D and that it had been cashed. R1 further stated that when Housekeeping Staff D asked for the money, she was in pain from a recent fall and had given her a check for the $300.00 so Housekeeping Staff D would leave her alone. On 05/27/24 at 02:03 PM, Administrative Nurse B notified R1's family. On 05/28/24 at unknown time, Administrative Nurse B documented that Administrative Staff A spoke with R1's family who stated that he did not want the police involved since Housekeeping Staff D had been fired and the monies were refunded to R1.
On 06/27/24 and untimed, revealed Administrative Staff L documented that on 05/27/24, she was informed that an unknown staff member had asked a resident for money. Administrative Staff L documented that she questioned R1 if it was true and R1 said yes. Administrative Staff L called Administrative Nurse B while in R1's room and completed a video call with R1.
An undated and untimed witness statement of Housekeeping Staff J documented that on 05/24/24, Housekeeping Staff D and Housekeeping Staff J discussed one resident stating Housekeeping Staff D asked him for 300.00 dollars. Housekeeping Staff J documented that she had a teachable moment with Housekeeping Staff D, that staff should not even joke or even discuss things in front of residents, that she could get in trouble.
On 06/27/24 and untimed, Housekeeping Staff J documented that on 05/27/24, Administrative Nurse B called her around 01:30 PM to ask her if she had heard that R1 was asked for money from Housekeeping Staff D. Housekeeping staff J documented she told Administrative Nurse B no. Housekeeping Staff J documented that on 05/28/24 she contacted Housekeeping Staff D and asked her to come to the facility to see her. Housekeeping Staff D replied at 02:25 PM, she was not able to come in. Housekeeping Staff J was unable to contact Housekeeping Staff D after that time.
On 06/26/24 at 03:12 PM, R1 stated Housekeeping Staff D borrowed $300 from her in the last 2-3 weeks and that Housekeeping Staff D stated that she would repay the loan the next day, but she never came back to the facility. She felt exploited due to the housekeeper repeatedly asking for money and she would not take no for an answer, so R1 finally wrote the housekeeper a check so she would just leave her alone. R1 reported the housekeeper no longer worked at the facility. The facility offered to reimburse her for the lost funds from her (Housekeeping Staff D's) last paycheck.
On 06/27/24 at 11:22 AM, R2 reported Housekeeping Staff D stated she wanted someone to give her $300.00 and would point at other residents walking by R2's room and ask R2 if she thought that they (the other residents) would give her money. R2 revealed that she told Housekeeping Staff D that she had no money and to not ask her again for any money.
On 06/26/24 at 04:50 PM, Administrative Nurse B revealed that her expectation was for staff to notify the Director of Nurses, social services, or the Administrator if there were allegations and then the proper notifications could be done.
On 06/26/24 at 03:50 PM, Administrative staff A confirmed the above information and stated that she did not notify law enforcement or the State Agency of the exploitation of the resident. She confirmed that they did terminate the offending employee and initiated reimbursement to the resident for the lost funds and stated that no solicitation and no gratuities were covered in the employee handbook which documented that solicitation of or by employees was prohibited.
The facility's undated Abuse, Neglect and Exploitation Prevention policy documented that the facility would prohibit and prevent exploitation of residents and misappropriation of resident property. Further, defined exploitation as the unfair treatment or taking advantage of a resident for personal gain through the use of manipulation, intimidation or coercion. The facility would comply with the seven-step approach to detection and prevention. If an allegation is made, notification would make a report with local law enforcement agency and the State Agency, as required.
The facility failed to ensure the timely reporting of alleged exploitation to the State Agency (SA- a state governmental agency that provides oversight for the Centers for Medicare & Medicaid Services [CMS - the federal government agency that administers the nation's major healthcare programs]) or local law enforcement, as required, when the facility failed to report the allegation of exploitation of Resident (R)1 when Housekeeping Staff D coerced the resident to write her a check for $300.00.
On 06/27/24 at 10:10 AM, Administrative Staff A was provided the Immediate Jeopardy (IJ) template for failure to report to the State Agency and local law enforcement for the exploitation of the residents, which placed them in immediate jeopardy.
The facility submitted an acceptable plan for removal of the immediate jeopardy on 06/27/24 at 01:33 PM which included the following:
1. On 06/27/24 at 10:52 AM, all staff would receive either group or individual ANE training with a member of management.
2. On 06/27/24 at 10:52 AM, all staff were notified by the facility's communication app that prior to returning to work, staff must receive ANE training with a member of management.
3. On 06/27/24 at 10:52 AM, the facility's Medical Director and R1's primary care provider (PCP) was notified about the alleged exploitation of R1.
4. On 06/27/24 at 10:52 AM, the Long-Term State Ombudsman was notified about the alleged exploitation of R1.
5. On 06/27/24 at 11:30 AM an ad-hoc QAPI (quality assurance process improvement) meeting was held.
The survey team validated the immediate jeopardy was removed on 06/27/24 at 01:40 PM, following the facility's implementation of the plan for removal of the immediate jeopardy.
The deficient practice remained at a scope and severity level of a F following the removal of the immediate jeopardy.
CRITICAL
(L)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Investigate Abuse
(Tag F0610)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 25 residents. The sample included six residents reviewed for misappropriation and exploitation...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 25 residents. The sample included six residents reviewed for misappropriation and exploitation. Based on interview and record review, the facility failed to thoroughly investigate incidents of misappropriation of funds and failed to protect the residents from further misappropriation when Housekeeping Staff D coerced Resident (R)1 to write her a check for $300.00. This deficient practice placed R1and other residents of the facility in immediate jeopardy and placed the residents at risk for further misappropriation of funds.
Findings included:
- R1's Electronic Health Record (EHR) revealed diagnoses that included interstitial pulmonary disease (a disorder that causes progressive scarring of lung tissue), major depressive disorder (a major mood disorder which causes persistent feelings of sadness), and anxiety disorder (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).
The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 was independent with all cares.
The Quarterly MDS dated 06/14/24, documented a BIMS score of 15, which indicated intact cognition. R1 was independent with all cares.
Review of witness statements revealed the following:
On 06/27/24, untimed, R1 documented that on 05/22/24 at unknown time, Housekeeping Staff D came into her room and asked for $500.00 with the promise to repay her the next day. R1 stated that she could not loan out that much money. On 05/23/24, Housekeeping Staff D returned to R1's room and requested a smaller loan of $300. R1 stated she was in pain from a recent fall and just wanted Housekeeping Staff D to leave her room, so she wrote a check for $300.00.
Undated and untimed witness statement revealed Administrative Staff A documented on 05/27/24 at 01:38 PM, Administrative Nurse B notified her that Housekeeping Staff D requested $300.00 from R1 and that R1 wrote Housekeeping Staff D a check. Administrative Staff A documented she gave the directive to terminate Housekeeping Staff D effective immediately. Administrative Staff A then notified R1's family of the events, that Housekeeping Staff D was terminated, and the lost funds would be refunded to the resident. Administrative Staff A documented that two termination letters were sent to Housekeeping Staff D's last known address via certified mail, which were returned as undeliverable. Administrative Staff A further documented she held a staff meeting with the department managers and directed them to hold individual department meetings to advise the staff of what had happened and to reinforce the ANE training, specific to taking money from residents.
Undated and untimed witness statement revealed Administrative Nurse B documented that on 05/27/24 at 01:32 PM, Administrative Staff L notified her of a possible exploitation of R1 and was going to confirm with R1. On 05/27/24 at 01:38 PM, Administrative Nurse B notified Administrative Staff A and Housekeeping Staff J. On 05/27/24 at 01:52 PM, a video call was completed between Administrative Nurse B with Administrative Staff L and R1 and R1 confirmed that she had written a check to Housekeeping Staff D and that it had been cashed. R1 further stated that when Housekeeping Staff D asked for the money, she was in pain from a recent fall and had given her a check for the $300.00 so Housekeeping Staff D would leave her alone. On 05/27/24 at 02:03 PM, Administrative Nurse B notified R1's family. On 05/28/24, the following day, at an unknown time, Administrative Nurse B documented that Administrative Staff A spoke with R1's family who stated that he did not want the police involved since Housekeeping Staff D had been fired and the monies were refunded to R1.
On 06/27/24 and untimed revealed Administrative Staff L documented that on 05/27/24, she was informed that an unknown staff member had asked a resident for money. Administrative Staff L documented that she questioned R1 if it was true and R1 said yes. Administrative Staff L called Administrative Nurse B while in R1's room and completed a video call with R1.
An undated and untimed witness statement of Housekeeping Staff J documented that on 05/24/24, Housekeeping Staff D and Housekeeping Staff J discussed one resident stating Housekeeping Staff D asked him for 300.00 dollars. Housekeeping Staff J documented that she had a teachable moment with Housekeeping Staff D, that staff should not even joke or even discuss things in front of residents, that she could get in trouble.
On 06/27/24 and untimed, Housekeeping Staff J documented that on 05/27/24, Administrative Nurse B called her around 01:30 PM to ask her if she had heard that R1 was asked for money from Housekeeping Staff D. Housekeeping staff J documented she told Administrative Nurse B no. Housekeeping Staff J documented that on 05/28/24 she contacted Housekeeping Staff D and asked her to come to the facility to see her. Housekeeping Staff D replied at 02:25 PM, she was not able to come in. Housekeeping Staff J was unable to contact Housekeeping Staff D after that time.
On 06/26/24 at 03:12 PM, R1 stated Housekeeping Staff D borrowed $300 from her in the last 2-3 weeks and that Housekeeping Staff D stated that she would repay the loan the next day, but she never came back to the facility. She felt exploited due to the housekeeper repeatedly asking for money and she would not take no for an answer, so R1 finally wrote the housekeeper a check so she would just leave her alone. R1 reported the housekeeper no longer worked at the facility. The facility offered to reimburse her for the lost funds from her (Housekeeping Staff D's) last paycheck.
On 06/27/24 at 11:22 AM, R2 reported Housekeeping Staff D stated she wanted someone to give her $300.00 and would point at other residents walking by R2's room and ask R2 if she thought that they (the other residents) would give her money. R2 revealed that she told Housekeeping Staff D that she had no money and to not ask her again for money.
On 06/26/24 at 04:40 PM, Certified Nurse Aide (CNA) F, CNA G, CNA H revealed they all had abuse, neglect, and exploitation (ANE) training last October (2023), and in April 2024, with an online learning module. They all revealed that they had not received recent ANE training of any type since April 2024.
On 06/26/24 at 04:43 PM, Dietary K stated the last time she had received ANE training was in April of 2024.
On 06/26/24 at 04:48 PM, Licensed Nurse (LN) C revealed she had her last ANE training via an on-line learning module in April 2024.
On 06/26/24 at 04:50 PM, Administrative Nurse B revealed that her expectation was for staff to notify the Director of Nurses, social services, or the Administrator if there were allegations and then the proper notifications could be done. Additionally stated that staff were educated, however as of 06/27/24 at 09:00 AM, the facility failed to produce documentation of staff training after the incident.
On 06/26/24 at 03:50 PM, Administrative staff A confirmed the above information and stated that she did not notify law enforcement or the State Agency of the exploitation of the resident. She confirmed that they did terminate the offending employee and initiated reimbursement to the resident for the lost funds and stated that no solicitation and no gratuities were covered in the employee handbook which documented that solicitation of or by employees was prohibited.
The facility's undated Abuse, Neglect and Exploitation policy documented that the facility would prohibit and prevent exploitation of residents and misappropriation of resident property. Further, defined exploitation as the unfair treatment or taking advantage of a resident for personal gain through the use of manipulation, intimidation or coercion. The facility would comply with the seven-step approach to detection and prevention. If an allegation is made, notification would make a report with local law enforcement agency and the State Agency, as required.
The facility failed to thoroughly investigate incidents of misappropriation of funds and failed to protect the residents from further misappropriation when Housekeeping Staff D coerced Resident (R)1 to write her a check for $300.00. This deficient practice placed R1and other residents of the facility in immediate jeopardy and placed the residents at risk for further misappropriation of funds.
On 06/27/24 at 10:10 AM, Administrative Staff A was provided the Immediate Jeopardy (IJ) template for failure to prevent exploitation of the residents, which placed them in immediate jeopardy.
The facility submitted an acceptable plan for removal of the immediate jeopardy on 06/27/24 at 01:33 PM which included the following:
1. On 06/27/24 at 10:52 AM, all staff would receive either group or individual ANE training with a member of management.
2. On 06/27/24 at 10:52 AM, all staff were notified by the facility's communication app that prior to returning to work, staff must receive ANE training with a member of management.
3. On 06/27/24 at 10:52 AM, the facility's Medical Director and R1's primary care provider (PCP) was notified about the alleged exploitation of R1.
4. On 06/27/24 at 10:52 AM, the Long-Term State Ombudsman was notified about the alleged exploitation of R1.
5. On 06/27/24 at 11:30 AM an ad-hoc QAPI (quality assurance, process improvement) meeting was held.
The survey team validated the immediate jeopardy was removed on 06/27/24 at 01:40 PM, following the facility's implementation of the plan for removal of the immediate jeopardy.
The deficient practice remained at a scope and severity level of a F following the removal of the immediate jeopardy.
Feb 2024
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 22 residents with 12 residents included in the sample. Based on observation, interview, and re...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 22 residents with 12 residents included in the sample. Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for Resident (R) 18 related to interventions on the care plan related to a fracture of the Left elbow and Left wrist.
Findings included:
- Resident (R)18's signed physician orders dated 01/19/24 included the diagnoses of fracture of the left wrist (broken bone), fracture of the left elbow (broken bone in elbow), peripheral vascular disease (PVD - abnormal condition affecting the blood vessels), anorexia (lack or loss of appetite), and polyosteoarthritis (degenerative changes to one or many joints characterized by swelling and pain).
The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident was independent with her daily care. The resident received pain medication on schedule and as needed for frequent complaints of pain at an 8/10. The resident had no falls. Medications included antidepressant and opioid pain medications received daily.
The Significant Change in Status MDS dated [DATE] revealed a BIMS score of 15, indicating intact cognition. The resident had one major fall with fracture since the last assessment. Medications included antidepressant and opioid pain medications received daily.
R18's Care Plan dated 01/23/2023 revealed R18 was at risk for falls related to use of antidepressant and opioid medications that could potentially cause side effects that could lead to a fall, generalized weakness that may fluctuate from time to time. The resident had chronic pain related to arthritis.
Administer medications per physician orders. Monitor/document for side effects. Maintain the call light was within reach and encourage R18 to use the call light.
On 01/19/24, staff were to educate R18 to sit down when dressing and undressing to help prevent her from losing her balance.
The care plan lacked interventions related to fracture of left wrist and elbow with increased assistance required following fall with fracture and continuous use of a splint.
Review of the Electronic Health Record (EHR), on 01/19/2024 at 8:35 AM, an unwitnessed fall occurred in the bathroom. Activity at the time of the fall included the resident attempted to remove her sweatshirt above her head, lost her balance and fell. The resident complained of severe sharp pain in her left shoulder, elbow, and wrist. A hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) immediately developed on the outer left elbow. R18's family transferred R18 to the emergency room of a local hospital per private car.
On 1/20/2024 at 12:15 AM, R18 returned to the facility with a diagnosis of a closed fracture of the left elbow. Instructions included to wear a sling until she is seen by an orthopedic physician. Nursing staff should call and make the appointment as soon as possible. The resident refused an ice pack, however received pain medication at the hospital.
On 02/05/24 at 04:01 PM, R18 returned from a follow up appointment with the orthopedic physician. Instructions included staff could remove the left arm brace for bathing twice weekly.
Observation on 02/06/24 at 10:30 AM revealed R18 wore a sling to her left arm.
On 02/06/24 at 02:30 PM, R18 reported she had gone to the bathroom to get ready to bed. Somehow while taking her shirt off, she got wrapped up and lost her balance and fell. She reported she needed to wear the sling for four weeks.
On 02/06/24 at 10:00 AM, Licensed Nurse G reported she did not write anything on the care plan. She thought just the MDS nurse had control to write on the care plans.
On 02/06/24 at 10:10 AM, Administrative Nurse E verified staff did not care plan the resident's fractures/follow up care.
On 02/07/24 at 09:00 AM, Administrative staff A reported the care plans had been a problem for months now, and the facility attempting to retrain staff to write the care plans.
A Policy for Comprehensive Care Plans was requested on 02/08/24 though no policy received.
The facility failed to develop a care plan for fractures or treatment of fractures following fall on 01/19/24.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 22 with 12 residents included in the sample that included one resident sampled for respiratory...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 22 with 12 residents included in the sample that included one resident sampled for respiratory services. Based on observation. Interviews, and record review, the facility failed to obtain written orders regarding the rate of oxygen flow for one Resident (R)23, to receive per nasal cannula (a device used to deliver supplemental oxygen),and lack dates the oxygen tubing had been changed). In addition, the facility failed to label/date R23's oxygen tubing, to prevent adverse reactions from oxygen tubing.
Findings Included:
- The Physician Orders revealed Resident (R)23 had the following diagnosis that included chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing).
The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) revealed a score of 14, indicating intact cognition. R23 has shortness of breath or trouble breathing with exertion or laying flat.
The Care Plan dated 01/24/24, revealed R22 was at risk for impaired gas exchange related to a diagnosis of chronic obstructive pulmonary disease (COPD). Staff were to evaluate the resident for any change in level of consciousness, pulse oximetry (a level indicating the percentage of oxygen the blood carries), respiratory rate and effort. The care plan lacked guidance/information on the rate of oxygen to be administered.
The Physician Order dated 01/12/24, revealed oxygen per nasal cannula, two times a day, related to (COPD) for oxygen saturation rates below 88 percent (%) to 90%. The order lacked the rate flow regarding the oxygen.
Observation on 02/05/24 at 11:41 AM revealed R22's oxygen tubing attached to his concentrator and lacked a date when the tubing had been changed.
Observation on 02/06/24 at 07:45 AM, R22 was in the dining room. The portable oxygen tubing lacked a date when changed.
Interview with Licensed Nurse LN H on 02/07/24 at 12:41 PM, Licensed Nurse H reported oxygen tubing should be changed weekly on Tuesdays. Staff should check the physician orders for the rate of flow for the oxygen.
Interview with Administrative Nurse D on 02/07/24 at 02:15 PM, Administrative Nurse D reported it was the expectation for the charge nurses to have an order for the rate of oxygen. In addition, oxygen tubing should be changed weekly on Tuesdays.
The facility's policy for Administration of Oxygen revised 10/02/23, revealed the facility provides oxygen therapy for every user if prescribed by the resident's primary care physician. Set the flow meter to the rate ordered by the physician. Change cannula and tubing weekly, document the method of administration and liter flow as ordered.
The facility failed to obtain written physician orders which indicated the amount R22 would receive through the nasal cannula. In addition, staff failed to label/date the oxygen tubing weekly.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 22 with 12 residents included in the sample, that included five residents reviewed for unneces...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 22 with 12 residents included in the sample, that included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to obtain physician ordered parameters for insulin (hormone that the level of glucose in the blood) and lacked notification to the physician for one Resident (R) 22 when staff held the physician ordered insulin.
Findings included:
- The Physician's order revealed a diagnosis of type two diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin).
The admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status score of 15, indicating R22 had intact cognition. During the look back period, R22 received two days of injection with two days of receiving insulin.
The Medication Administration Record revealed Tresiba (injectable insulin), 30 units, subcutaneously (beneath the skin) in the morning, related to type two diabetes mellitus. Obtain blood glucose in the morning.
The Physician's order lacked a parameter to hold insulin or parameters when the physician must be notified.
The Nurse Progress Notes from 01/12/24 to 02/05/24 revealed staff held the insulin without the physician's order or without notification to the physician for the following:
On 01/12/24, the insulin held due to R22 did not eat.
On 01/13/24, the insulin held due to R22 not eating.
On 01/17/24, Tresiba held for fasting blood sugar of 80 milligrams per deciliter (mg/dl). Staff lacked notification of the insulin held to the physician for further directions.
On 01/22/24, the insulin held for fasting blood sugar of 106 (mg/dl). Staff lacked notification of the insulin held to the physician for further directions.
On 01/26/24, Tresiba insulin held for fasting blood sugar of 79 (mg/dl). Staff lacked notification of the insulin held to the physician for further directions.
On 01/29/24, the insulin held. The nurse progress notes lacked notification of the physician and lacked the reason staff held the insulin.
On 02/05/24, the insulin held. The nurse progress notes lacked notification of the physician and lacked the reason staff held the insulin.
On 02/07/24 at 12:45 PM. Licensed Nurse (LN) H reported it was the expectations for blood sugars/ insulin to have parameters.
On 02/07/24 at 02:15 PM, Administrative Nurse D reported it was expected for the facility to have parameters for insulin administration.
The facility's undated policy for Blood Glucose Monitoring lacked guidance/information regarding parameters for insulin or notification of the physician when insulin held.
The facility failed to obtain parameters related to insulin, and lacked notification of the physician when staff held the insulin without physician's orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected 1 resident
The facility census totaled 22 residents. Based on interview and record review, the facility failed to maintain an in-service training program for nurses' aides that was appropriate and effective to e...
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The facility census totaled 22 residents. Based on interview and record review, the facility failed to maintain an in-service training program for nurses' aides that was appropriate and effective to ensure the continuing competence of nurse aides. The facility identified five Certified Nurse Assistants (CNA's) had been employed over one year. One of the five CNAs lacked the required 12 hours of in-service training, and one other CNA lacked completed training in abuse, neglect, and exploitation (ANE) to ensure the continuing competence of nurse aides and appropriate care and services to all the residents of the facility.
Findings included:
- Review of a list of Certified Nursing Assistants (CNA) employment dates revealed only five CNAs had been employed for at least 12 months. Of the five employees, one lacked completed training in abuse, neglect, and exploitation (ANE) and one lacked the 12 hours required inservice.
On 12/13/23 the training log for CNA R had a total of 8.25 hours total for the year.
On 12/14/23 at 12:30 PM, CNA S had a total of 15.5 hours with no ANE training.
On 12/14/23 at 02:30 PM, Administrative staff A reported the facility had online training, but she did not have anyone to oversee to make sure staff watched what they needed/required.
A policy for the 12-hour training requirement was requested on 02/08/24, though no policy provided
The facility failed to provide one CNA with the required 12 hours of inservice training, and one CNA to include ANE training.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 22 with 12 residents in the sample. Based on observation, interviews, and record review the fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 22 with 12 residents in the sample. Based on observation, interviews, and record review the facility failed to complete a base line care plans on four of the new admits into the facility Resident (R) 12, R22, R23, and R127.
Finding included:
- The Physicians Orders revealed the following diagnoses for R 12 included primary hypertension (elevated blood pressure) and chronic bronchitis (inflammation of the bronchial tubes).
The admission Minimum Data Set dated 01/11/24 revealed a Brief Interview for Mental Status (BIMS) a score of 15 indicating intact cognition.
R12 admitted to the facility on [DATE]. The record review indicated the base line care plan had not been completed with in 48 hours of admission.
Interview on 02/06/24 at 10:10 AM with Administrative Nurse E verified the resident had no baseline care plan. She had been working on the admissions (MDS) today (02/06/24). Administrative Nurse E reported she does not complete a care plan when a new resident admitted until she would complete the MDS and the Care Area Assessment (CAA).
Interview on 02/07/24 at 09:00 AM with Administrative Staff A, reported the care plan have been a problem for months and were attempting to retrain staff to write the care plans. She was unaware the baseline care plans were not completed.
The undated facility's policy for Baseline Care Plan revealed the facility will develop and initial person-centered plan within the first forty-eight (48) hours of admission for every resident. The baseline care plan will provide instructions for care of the resident.
The facility failed to develop a baseline care plan for R12 to guide nursing staff in the care of the resident.
- The Physician Orders for Resident (R) 22 diagnoses included wedge compression fracture of unspecified lumbar vertebra ( collapse of a vertebra), and diabetes mellitus type two (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin).
The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R22 received two days of injections, indicating two days of insulin during the look back period.
Review of the admission care plan dated for R 22 indicated a base line care plan had not been initiated with in 48 hours of admission date of 01/06/24. On 01/26/24, staff completed R22's care plan.
Interview on 02/06/24 at 10:10 AM with Administrative Nurse E verified the resident had no baseline care plan. She had been working on the admissions (MDS) today (02/06/24). Administrative Nurse E reported she does not complete a care plan when a new resident admitted until she would complete the MDS and the Care Area Assessment (CAA).
Interview on 02/07/24 at 09:00 AM with Administrative Staff A, reported the care plan have been a problem for months and were attempting to retrain staff to write the care plans. She was unaware the baseline care plans were not completed.
The undated facility's policy for Baseline Care Plan revealed the facility would develop and initial person-centered plan within the first forty-eight (48) hours of admission for every resident. The baseline care plan will provide instructions for care of the resident.
The facility failed to develop a baseline care plan for R22 to guide nursing staff in the care of the resident.
- The Physician Orders for Resident (R)23 included the following diagnosis of chronic obstructive pulmonary disease unspecified (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and congestive heart failure (a condition with low heart output and the body becomes congested with fluid).
The admission Minimal Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. R23 has shortness of breath or trouble breathing with exertion lying flat, and received oxygen therapy.
Review of the admission dated for R 23 indicated a base line care plan had not been initiated with in 48 hours of admission date of 01/06/24. On 01/26/24 a care plan had been completed for R23.
Interview on 02/06/24 at 10:10 AM with Administrative Nurse E verified the resident had no baseline care plan. She had been working on the admissions (MDS) today (02/06/24). Administrative Nurse E reported she does not complete a care plan when a new resident admitted until she would complete the MDS and the Care Area Assessment (CAA).
Interview on 02/07/24 at 09:00 AM with Administrative Staff A, reported the care plan have been a problem for months and were attempting to retrain staff to write the care plans. She was unaware the baseline care plans were not completed.
The undated facility's policy for Baseline Care Plan revealed the facility will develop and initial person-centered plan within the first forty-eight (48) hours of admission for every resident. The baseline care plan will provide instructions for care of the resident.
The facility failed to develop a baseline care plan for R23 to guide nursing staff in the care of the resident.
- Resident (R) 127's signed physician orders dated 01/29/24 revealed the following diagnoses: Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).
The Entry tracking record Minimum Data Set (MDS) dated [DATE] revealed R127 admitted to the facility on [DATE].
The admission MDS dated [DATE], revealed a Brief Interview for Mental Status score of 11, indicating moderately impaired cognition. R127 had other behavioral symptoms not directed toward others daily and wandered daily. It was very important for R127 to listen to music, be around pets, participate in religious services.
The facility lacked a baseline care plan developed as of 02/05/24 to guide staff for resident cares.
Review of the record review indicated the following:
On 01/31/24 at 12:35 PM, R127 finished lunch and attempted to leave the facility. Staff was able to distracted her.
On 02/01/24 at 01:15 PM, R127 had anxiety and wanted to go home. Staff redirected her to the dayroom to sit on the couch and look at the birdcage.
On 02/03/24 at 03:36 PM, R127 wandered looking to exit and go home.
On 02/04/24 at 04:49 PM, R127 was exit seeking.
On 02/04/24 at 10:13 PM, R127 was exit seeking.
On 02/05/24 at 03:27 PM, R127 anxiously paced while trying to leave the facility.
Review of the Activities Calendar for February 2024 indicated a morning activity and at least one afternoon activity scheduled every day. No activities witnessed the days of survey.
Observation on 02/05/24 at 11:00 AM R127 ambulated down the hallway.
Observation on 02/06/24 at 02:00 PM R 127 wandering ad lib. There was no activities that occurred in the facility.
Observation on 02/06/24 at 04:00 PM revealed the resident continued to wander. No activities or diversional activities provided in the facility.
Interview on 02/06/24 at 10:10 AM with Administrative Nurse E verified the resident had no baseline care plan. She had been working on the admissions (MDS) today (02/06/24). Administrative Nurse E reported she does not complete a care plan when a new resident admitted until she would complete the MDS and the Care Area Assessment (CAA).
On 02/06/24 at 10:30 AM Certified Nursing Assistant (CNA) M reported the resident just walks around and reported if the facility had some activities, it might distract her a little. CNA M reported the facility lacked activities since staff quit last month.
On 02/06/24 at 10:40 AM, Certified Medication Aide (CMA) O reported the resident was very restless and going into other resident rooms and was exit seeking. Staff have to redirect the resident frequently, and reported if there were activities, that might occupy the resident for a while.
On 02/07/24 at 10:00 AM Social Service staff N reported the facility did not have many activities as it was her responsibility to try to provide activities, but she also had to provide social services and transportation, so there was little time for any activity for the residents.
On 02/06/24 at 10:00 AM Licensed Nurse G reported she did not really keep up with if there are activities going on at the facility.
Interview on 02/07/24 at 09:00 AM with Administrative Staff A, reported the care plan have been a problem for months and were attempting to retrain staff to write the care plans. She was unaware the baseline care plans were not completed.
The undated facility's policy for Baseline Care Plan revealed the facility would develop and initial person-centered plan within the first forty-eight (48) hours of admission for every resident. The baseline care plan will provide instructions for care of the resident.
The facility failed to develop a baseline care plan for R127 to guide nursing staff in the care of the resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 22 residents with 12 residents included in the sample. Based on observation, interview, and record ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 22 residents with 12 residents included in the sample. Based on observation, interview, and record review, the facility failed to provide scheduled activities to prevent boredom and impaired psychosocial well-being for the residents that were confused and wandered in the facility.
Findings included:
- Resident (R) 127's signed physician orders dated 01/29/24 revealed the following diagnoses: Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).
The Entry tracking record Minimum Data Set (MDS) dated [DATE] revealed R127 admitted to the facility on [DATE].
The admission MDS dated [DATE], revealed a Brief Interview for Mental Status score of 11, indicating moderately impaired cognition. R127 had other behavioral symptoms not directed toward others daily and wandered daily. It was very important for R127 to listen to music, be around pets, participate in religious services.
The facility lacked a baseline care plan developed as of 02/05/24.
Review of the record review indicated the following:
On 01/31/24 at 12:35 PM, R127 finished lunch and attempted to leave the facility. Staff was able to distracted her.
On 02/01/24 at 01:15 PM, R127 had anxiety and wanted to go home. Staff redirected her to the dayroom to sit on the couch and look at the birdcage.
On 02/03/24 at 03:36 PM, R127 wandered looking to exit and go home.
On 02/04/24 at 04:49 PM, R127 was exit seeking.
On 02/04/24 at 10:13 PM, R127 was exit seeking.
On 02/05/24 at 03:27 PM, R127 anxiously paced while trying to leave the facility.
Review of the Activities Calendar for February 2024 indicated a morning activity and at least one afternoon activity scheduled every day. No activities witnessed the days of survey.
Observation on 02/05/24 at 11:00 AM R127 ambulated down the hallway.
Observation on 02/06/24 at 02:00 PM R 127 wandering ad lib. There was no activities that occurred in the facility.
Observation on 02/06/24 at 04:00 PM revealed the resident continued to wander. No activities or diversional activities provided in the facility.
On 02/06/24 at 10:30 AM Certified Nursing Assistant (CNA) M reported the resident just walks around and reported if the facility had some activities, it might distract her a little. CNA M reported the facility lacked activities since staff quit last month.
On 02/06/24 at 10:40 AM, Certified Medication Aide (CMA) O reported the resident was very restless and going into other resident rooms and was exit seeking. Staff have to redirect the resident frequently, and reported if there were activities, that might occupy the resident for a while.
On 02/07/24 at 10:00 AM Social Service staff N reported the facility did not have many activities as it was her responsibility to try to provide activities, but she also had to provide social services and transportation, so there was little time for any activity for the residents.
On 02/06/24 at 10:00 AM Licensed Nurse G reported she did not really keep up with if there are activities going on at the facility.
Review of the undated facility policy for Life Enhancement and Activity Programming revealed the facility would provide, based on the comprehensive assessment and care plan and preferences of each resident, an ongoing program to support residents in their choice of activities.
The facility failed to provide scheduled activities to prevent boredom and impaired psychosocial well-being for the confused, wantering residents of the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
The facility reported a census of 22 residents with two separate units and two resident kitchens. Based on observation, interview, and record review, the facility failed to store foods safely and sani...
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The facility reported a census of 22 residents with two separate units and two resident kitchens. Based on observation, interview, and record review, the facility failed to store foods safely and sanitary manner to prevent food borne illnesses, for the 22 residents of the facility, in two of two resident kitchens.
Findings included:
- On 02/05/24 at 10:30 AM, an initial tour of the kitchen with dietary staff BB, revealed the following items of concern in the refrigerator:
Two cartons of mighty shake (protein supplement drink) documented a thaw date of 12/23/23 and a warning on the label for the staff to use it within 14 days of the thaw date (01/06/24).
A plastic bowl of grated cheese and a package of flour tortillas, both without an open date or a use by date. Dietary Staff BB verified the expired and undated items above.
A continued initial tour, on 02/05/24 of the kitchen in house two, with Dietary Staff CC, revealed the following concerns in the refrigerator:
A carton of a thawed mighty shake, with a thaw date of 12/23/23 and a warning label to staff to use it within 14 days of thawing (01/06/24).
A carton of half and half (milk and cream) with an expiration date of 01/15/24 (22 days after it expired). Dietary Staff CC verified the expired and undated items above.
On 02/06/24 at 10:00 AM, Housekeeping Supervisor V reported it was the responsibility of the dietary staff working in the kitchens to monitor the stored food for undated, unmarked items that needed removed.
Review of the facility's policy for Dietary Purchases, Receipt and Storage dated 04/21/13, revealed the policy lacked guidance on dating and storing of open food items or monitoring the food items for expiration dates.
The facility failed to store foods safely and sanitarily to prevent food borne illnesses, for the 22 residents of the facility, in two of two kitchens.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Data
(Tag F0851)
Could have caused harm · This affected most or all residents
The facility reported a census of 22 residents. Based on interview and record review, the facility failed to submit complete and accurate staffing information to the federal regulatory agency through ...
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The facility reported a census of 22 residents. Based on interview and record review, the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ) when the facility failed to submit staffing hourly data for all nursing personnel by the required deadline.
Findings included:
- Review of the Fiscal Year (FY), Quarter 1- 2023 (October 1 -December 31), the facility failed to have Licensed Nursing Coverage 24 Hours/Day for the following:
On 10/01/23; Saturday (SA), 11/06/23, Sunday (SU); 11/19/23 (SA); 12/03/23, (SA); 12/10/23 (SA); and 12/11/23, (SU).
Review of the FY Quarter 2-2023 (January 1- March 31), the facility failed to have Licensed Nursing Coverage 24 Hours/Day for the following:
On 01/07, (SA); 01/08, (SU); 01/21, (SA); 02/18, (SA); 02/19, (SU); 03/11, (SA); 03/12, (SU); 03/19, (SU); 03/25, (SA); and 03/26 (SU).
Review of FY Quarter 3- 2023 (April 1 -June 30), the facility failed to have Licensed Nursing Coverage 24 Hours/Day for the following:
On 04/08 (SA); 04/09 (SU); 04/22 (SA); 04/23 (SU); 04/29 (SA); 05/07 (SU); 05/20 (SA); 05/21 (SU); 06/10 (SA) and 06/25 (SU).
Review of FY Quarter 4- 2023 (July 1 -September 30), the facility failed to have Licensed Nursing Coverage 24 Hours/Day for the following:
On 07/30 (SU); 09/03 (SU); 09/04 Monday (MO); 09/23 (SA); 09/24 (SU).
Review of the nursing schedule and clocking sheets for the above dates revealed adequate hours to account for 24-hour nursing coverage.
Interview on 02/06/24 at 02:00 PM, Administrative staff A reported all the hours come directly off the facility's staffing program and she does not know how some hours transfer and others did not. They will have to check their system.
Review of the facility's policy for Mandatory Submission of Uniform Format Staffing Information (PBJ) dated 10/16/22, revealed it is the policy of the facility to complete submission of staffing information format as specified by regulatory requirements. The facility has hired ( named management company) that will electronically submit to Centers of Medicare and Medicaid Services (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by the Centers of Medicare and Medicaid Services (CMS).
The facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ) when the facility failed to submit staffing hourly data for all nursing personnel by the required deadline.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
The facility had a census of 22 residents the sample included 12 residents. Based on observation, record review, and interview, the facility's Quality Assessment and Assurance Program failed to provid...
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The facility had a census of 22 residents the sample included 12 residents. Based on observation, record review, and interview, the facility's Quality Assessment and Assurance Program failed to provide good faith efforts to identify multiple issue of concern for 22 residents residing in the facility.
Findings included:
- The facility failed to develop a baseline care plan for all new admission with in 48 hours for the following Resident (R12), R22, R23 and R127 with direction to staff on providing cares. Refer to F655.
The facility failed to develop a comprehensive care plan for Resident R15. Refer to F656.
The facility failed to provide activities for confused wandering residents. Refer to F679.
The facility failed to provide accurate physicians orders regarding respiratory care for R23. Refer to F695.
The facility failed to obtain physician's orders to hold insulin, documentation notification of the physician when holding the insulin of R22. Refer to 757.
The facility failed to remove outdated food items that could possible be served to the 22 Residents. Refer to F812.
The facility failed to report complete and accurate staffing information to the federal regulatory agency through Payroll Based Journalling (PBJ). Refer to F851.
The facility failed to provide a safe, functional, sanitary environment for the 22 residents who resident in the facility. Refer to F880.
The facility failed to ensure the nursing staff received the in services/or education recommended for 12 hours education each year for one of the five certified nurse aides. Refer to F947.
The facility's policy for Quality Assurance Performance Improvement Policy, revised on 10/05/22, revealed the facility will ensure that all staff will consistently develop processes and system to provide safe, effective and optimal care and services to each resident residing at or receiving service. The facility maintains documentation and demonstrates evidence of it ongoing Quality Assurance Performance Improvement/ Quality Assessment and Assurance (QAPI/QAA) program that meets regulatory requirements including but not limited to systems and reports demonstration systematic identification, reporting , investigation, analysis, and prevention adverse events and documentation demonstrating the development, implementation and evaluation of corrective action or performance improvement actives.
The facility failed to identify, develop and implement appropriate plans of action to have an effective quality assurance program that identified and addressed the above issue involving multiple concerns placing the 22 resident who resident in the facility at risk for mental and/or physical decline.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
The facility reported a census of 22 residents. Based on interviews the facility failed to provide a safe and sanitary environment by the failure to use appropriate disinfectant to sanitize the washin...
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The facility reported a census of 22 residents. Based on interviews the facility failed to provide a safe and sanitary environment by the failure to use appropriate disinfectant to sanitize the washing machines after washing clothes/linens during an outbreak of COVID-19 (highly contagious respiratory virus).
Findings included:
- On 02/07/24 at 08:17 AM, Laundry Aide U reported staff utilized the small washing machine for biohazard material. Staff use vinegar to run through the washing machine after staff finish the biohazard linens/laundry. Laundry Aide U verified bleach or no other disinfectant utilized for sanitization inside the washer.
On 02/07/23 at 01:28 PM, Laundry staff V revealed staff no longer use bleach to disinfect. Staff use vinegar to disinfect. Laundry staff V verified there was no information in the facility to indicate vinegar was to be used as a disinfectant.
The facility's undated policy for Laundry Protocols revealed the facility to prevent the spread of infection by appropriate separation, collection, laundry, and storage of laundry. At the end of each laundry shift, all machines and dryers will be cleaned with acceptable sanitizing solution following manufacturer recommendation for wet contact times.
The facility failed to provide a safe and sanitary environment by the failure to use appropriate disinfectant to sanitize the washing machines after washing clothes/linens during an outbreak of COVID.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 3 life-threatening violation(s). Review inspection reports carefully.
- • 13 deficiencies on record, including 3 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $13,627 in fines. Above average for Kansas. Some compliance problems on record.
- • Grade F (7/100). Below average facility with significant concerns.
Bottom line: This facility has 3 Immediate Jeopardy findings. Serious concerns require careful evaluation.
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About This Facility
What is The Shepherd'S Center's CMS Rating?
THE SHEPHERD'S CENTER does not currently have a CMS star rating on record.
How is The Shepherd'S Center Staffed?
Detailed staffing data for THE SHEPHERD'S CENTER is not available in the current CMS dataset.
What Have Inspectors Found at The Shepherd'S Center?
State health inspectors documented 13 deficiencies at THE SHEPHERD'S CENTER during 2024. These included: 3 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 10 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates The Shepherd'S Center?
THE SHEPHERD'S CENTER is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 28 certified beds and approximately 22 residents (about 79% occupancy), it is a smaller facility located in CIMARRON, Kansas.
How Does The Shepherd'S Center Compare to Other Kansas Nursing Homes?
Comparison data for THE SHEPHERD'S CENTER relative to other Kansas facilities is limited in the current dataset.
What Should Families Ask When Visiting The Shepherd'S Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is The Shepherd'S Center Safe?
Based on CMS inspection data, THE SHEPHERD'S CENTER has documented safety concerns. Inspectors have issued 3 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 0-star overall rating and ranks #100 of 100 nursing homes in Kansas. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at The Shepherd'S Center Stick Around?
THE SHEPHERD'S CENTER has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was The Shepherd'S Center Ever Fined?
THE SHEPHERD'S CENTER has been fined $13,627 across 1 penalty action. This is below the Kansas average of $33,215. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is The Shepherd'S Center on Any Federal Watch List?
THE SHEPHERD'S CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.