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62/100COLBY OPERATOR, LLC Inspection Report, Violations & Safety Grade (COLBY, Kansas)
105 EAST COLLEGE DRIVE, COLBY, Kansas 67701
Phone: 7854626721
CMS Overall:2/5
Overview & Bed Count
Certified Beds
40
Avg Residents/Day
33.3
Ownership
For profit - Partnership
Provider Type
Medicare and Medicaid
County
Thomas
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall2/5
Health3/5
Staffing3/5
Quality1/5
Nurse Staffing Check
| Metric | This Facility | Kansas Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.49 | 0.73 | -0.23 |
| Total Nurse Hours per Resident per Day | 4.01 | 4.13 | -0.12 |
| CMS Staffing Rating | 3/5 | 3.5/5 | - |
| Nursing Staff Turnover | 70.5% | 48% | - |
Health Citation History
26 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-06-11 | Nursing and Physician Services Deficiencies | Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | F – Moderate Harm Potential |
| 2025-06-11 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2025-06-11 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2025-06-11 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2025-06-11 | Pharmacy Service Deficiencies | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D – Moderate Harm Potential |
| 2024-08-12 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | J – Immediate Jeopardy |
| 2023-09-28 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2023-09-28 | Administration Deficiencies | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | F – Moderate Harm Potential |
| 2023-09-28 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | F – Moderate Harm Potential |
| 2023-09-28 | Environmental Deficiencies | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | F – Moderate Harm Potential |
| 2023-09-28 | Pharmacy Service Deficiencies | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | E – Moderate Harm Potential |
| 2023-09-28 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D – Moderate Harm Potential |
| 2023-09-28 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2023-09-28 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2023-09-28 | Resident Assessment and Care Planning Deficiencies | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | D – Moderate Harm Potential |
| 2023-09-28 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2023-09-28 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2023-09-28 | Quality of Life and Care Deficiencies | Provide care or services that was trauma informed and/or culturally competent. | D – Moderate Harm Potential |
| 2023-09-28 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | D – Moderate Harm Potential |
| 2023-09-28 | Nursing and Physician Services Deficiencies | Post nurse staffing information every day. | C – Minimal Harm Potential |
| 2022-05-12 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2022-05-12 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2022-05-12 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2022-05-12 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2022-05-12 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2022-05-12 | Pharmacy Service Deficiencies | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D – Moderate Harm Potential |
Fire Safety Citation History
37 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-06-11 | Egress Deficiencies | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | F – Moderate Harm Potential |
| 2025-06-11 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2025-06-11 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2025-06-11 | Egress Deficiencies | Install emergency lighting that can last at least 1 1/2 hours. | E – Moderate Harm Potential |
| 2025-06-11 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E – Moderate Harm Potential |
| 2025-06-11 | Smoke Deficiencies | Properly select, install, inspect, or maintain portable fire extinguishes. | E – Moderate Harm Potential |
| 2025-06-11 | Smoke Deficiencies | Install smoke barrier doors that can resist smoke for at least 20 minutes. | E – Moderate Harm Potential |
| 2025-06-11 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | E – Moderate Harm Potential |
| 2025-06-11 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | E – Moderate Harm Potential |
| 2023-09-28 | Emergency Preparedness Deficiencies | Develop and maintain an Emergency Preparedness Program (EP). | F – Moderate Harm Potential |
| 2023-09-28 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2023-09-28 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2023-09-28 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | E – Moderate Harm Potential |
| 2023-09-28 | Egress Deficiencies | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | E – Moderate Harm Potential |
| 2023-09-28 | Smoke Deficiencies | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | E – Moderate Harm Potential |
| 2023-09-28 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2023-09-28 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E – Moderate Harm Potential |
| 2023-09-28 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | E – Moderate Harm Potential |
| 2023-09-28 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | E – Moderate Harm Potential |
| 2023-09-28 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2023-09-28 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | D – Moderate Harm Potential |
| 2023-09-28 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | D – Moderate Harm Potential |
| 2022-05-12 | Emergency Preparedness Deficiencies | Establish an Emergency Preparedness Program (EP). | F – Moderate Harm Potential |
| 2022-05-12 | Emergency Preparedness Deficiencies | Develop Emergency Preparedness policies and procedures. | F – Moderate Harm Potential |
| 2022-05-12 | Emergency Preparedness Deficiencies | Develop a communication plan. | F – Moderate Harm Potential |
| 2022-05-12 | Emergency Preparedness Deficiencies | Establish emergency prep training and testing. | F – Moderate Harm Potential |
| 2022-05-12 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2022-05-12 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2022-05-12 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | F – Moderate Harm Potential |
| 2022-05-12 | Electrical Deficiencies | Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | F – Moderate Harm Potential |
| 2022-05-12 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | E – Moderate Harm Potential |
| 2022-05-12 | Egress Deficiencies | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | E – Moderate Harm Potential |
| 2022-05-12 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E – Moderate Harm Potential |
| 2022-05-12 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E – Moderate Harm Potential |
| 2022-05-12 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | E – Moderate Harm Potential |
| 2022-05-12 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | E – Moderate Harm Potential |
| 2022-05-12 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | D – Moderate Harm Potential |
Total Penalties & Fines
$40,381
Total Fine Amount (CMS)
1
Number of Fines
2
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2024-08-12 | Fine | $40,381 | - |
| 2024-08-12 | Payment Denial | - | 1 days starting 2024-09-10 |
Need Help Finding Safe Care?
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3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the COLBY area at no cost.
Find Safe, Vetted Facilities Near COLBY
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.