Facility Watch Inspection records for every certified US nursing home

THE Shepherd's Center

101 Cedar Ridge Drive
Cimarron, KS 67835
(620) 855-3498

Special Focus Facility — SFF Candidate
CCN
175570
Certified beds
28
Ownership
Non profit - Corporation

Nurse staffing

4.76
Total nurse staffing hours per resident per day, case-mix adjusted

Registered nurses: 1.77 hours per resident per day

Nursing staff turnover: 61% a year

Derived by CMS from the Payroll-Based Journal and refreshed quarterly.

Inspection history

Inspected November 17, 2025

13 citations · Health
D
F0628 No actual harm with potential for more than minimal harm · Isolated

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Deficient, Provider has date of correction · corrected December 10, 2025
D
F0641 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident receives an accurate assessment.

Deficient, Provider has date of correction · corrected December 10, 2025
D
F0655 No actual harm with potential for more than minimal harm · Isolated

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Deficient, Provider has date of correction · corrected December 10, 2025
D
F0656 No actual harm with potential for more than minimal harm · Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected December 10, 2025
D
F0657 No actual harm with potential for more than minimal harm · Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Deficient, Provider has date of correction · corrected December 10, 2025
E
F0636 No actual harm with potential for more than minimal harm · Pattern

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Deficient, Provider has date of correction · corrected December 10, 2025
F
F0730 No actual harm with potential for more than minimal harm · Widespread

Observe each nurse aide's job performance and give regular training.

Deficient, Provider has date of correction · corrected December 10, 2025
F
F0801 No actual harm with potential for more than minimal harm · Widespread

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Deficient, Provider has date of correction · corrected December 10, 2025
F
F0812 No actual harm with potential for more than minimal harm · Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected December 10, 2025
F
F0838 No actual harm with potential for more than minimal harm · Widespread

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Deficient, Provider has date of correction · corrected December 10, 2025
F
F0867 No actual harm with potential for more than minimal harm · Widespread

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Deficient, Provider has date of correction · corrected December 10, 2025
F
F0880 No actual harm with potential for more than minimal harm · Widespread

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected December 10, 2025
F
F0881 No actual harm with potential for more than minimal harm · Widespread

Implement a program that monitors antibiotic use.

Deficient, Provider has date of correction · corrected December 10, 2025

Inspected June 27, 2024

3 citations · from a complaint investigation · Health
J
F0602 Immediate jeopardy to resident health or safety · Isolated

Protect each resident from the wrongful use of the resident's belongings or money.

Deficient, Provider has date of correction · corrected July 10, 2024
L
F0609 Immediate jeopardy to resident health or safety · Widespread

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Deficient, Provider has date of correction · corrected July 10, 2024
L
F0610 Immediate jeopardy to resident health or safety · Widespread

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected July 10, 2024

Inspected February 8, 2024

10 citations · Health
D
F0656 No actual harm with potential for more than minimal harm · Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected March 1, 2024
D
F0695 No actual harm with potential for more than minimal harm · Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Deficient, Provider has date of correction · corrected March 1, 2024
D
F0756 No actual harm with potential for more than minimal harm · Isolated

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Deficient, Provider has date of correction · corrected March 1, 2024
D
F0947 No actual harm with potential for more than minimal harm · Isolated

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Deficient, Provider has date of correction · corrected March 1, 2024
E
F0655 No actual harm with potential for more than minimal harm · Pattern

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Deficient, Provider has date of correction · corrected March 1, 2024
E
F0679 No actual harm with potential for more than minimal harm · Pattern

Provide activities to meet all resident's needs.

Deficient, Provider has date of correction · corrected March 1, 2024
F
F0812 No actual harm with potential for more than minimal harm · Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected March 1, 2024
F
F0851 No actual harm with potential for more than minimal harm · Widespread

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Deficient, Provider has date of correction · corrected March 1, 2024
F
F0867 No actual harm with potential for more than minimal harm · Widespread

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Deficient, Provider has date of correction · corrected March 1, 2024
F
F0880 No actual harm with potential for more than minimal harm · Widespread

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected March 1, 2024

Penalties

DateTypeAmount
June 27, 2024Fine$13,627