Belleville Healthcare And Rehabilitation Center
2626 Wesleyan Dr, Belleville, KS 66935 · For profit - Corporation · 62 certified beds · (785) 527-5636 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Nov 2024
- it has 2 actual-harm citations
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $20,323 in federal fines (most recent 2025-09-16)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 18.5% | 17.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.0% | 4.9% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.2% | 1.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.2% | 2.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 6.5% | 6.5% | 6.5% | typical |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.5% | 4.3% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 20.6% | 16.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 13.3% | 23.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.0% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.1% | 4.4% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 21.5% | 22.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 21.5% | 18.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 11.1% | 1.9% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 50.0% | 73.8% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 27.1% | 22.4% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 5.6% | 11.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.47 | 1.80 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 4.61 | 2.13 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
31.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 53 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 20.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 39 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.24 therapist hours per resident per day in 2026Q1 — more than 32% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 50% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 31.8%CMS range 23.2–43.5 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.0%CMS range 6.6–16.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 20.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 10.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 17.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.1% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.3%CMS range 4.2–12.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.17 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 62 beds and averages 48.0 residents a day — about 77% occupied, or roughly 14 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.09 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.70 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.04 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.70 hrs/resident/day on weekends vs 3.25 on weekdays — 17% thinner on weekends. RN hours go from 0.71 to 0.67 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 51% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · G2025-09-16 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 48 residents. The sample included 12 residents, with three residents reviewed for restorative nursing services. Based on observation, interview, and record review, the facility failed to provide restorative nursing services to prevent further decrease in range of motion (ROM) for Resident (R) 40's left hand, which had limited mobility. This deficient practice resulted in actual harm when R40 had a significant decrease in ROM to the left hand, could not mobilize her wheelchair without staff assistance, voiced concern that an orthopedic (pertaining to bones) surgeon would have to rebreak her hand to repair it, and voiced pain in her left hand at all times.Findings included:- R40's Electronic Medical Record (EMR) documented diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and traumatic subdural hematoma (SDH- a serious condition, typically caused by head injury, where blood collects between the skull and the surface of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2024-12-17 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 34 residents with three residents reviewed for unintended weight loss. Based on record review, observation, and interview, the facility failed to obtain consistent weights to establish a baseline, failed to identify and respond to progressive weight loss with intervention and increased assistance, and failed to follow the Registered Dietician (RD) recommendations to provide nutritional support for Resident (R)1. Subsequently, R1 had a significant unintended weight loss. This deficient practice also placed R1 at risk for decreased nourishment and delayed wound healing. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), major depressive disorder (major mood disorder which causes persistent feelings of sadness),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-09-16 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct 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.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 48 residents. The sample included 12 residents. Based on observations, interviews, and record review, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during the day-to-day operations and emergencies. Findings included:- On 09/15/25, Administrative Nurse D provided a Facility Assessment updated 04/28/25. A review of the assessment revealed the following:The assessment identified the required staffing needs per day but failed to identify the specific staffing needs by shift for the weekends.The assessment failed to identify the resident's acuity for care needs.The assessment failed to provide a detailed emergency staffing plan in the event of emergent situations.On 09/15/25 at 03:00 PM, Consultant HH stated the facility assessment that had previously been given to the survey team was not the correct facility assessment. Consultant HH gave a new facility assessment, stating, This is the actual facility assessment. Consultant HH stated Administrative Nurse D…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-09-16 · tag F0801 — patternEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 48 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the residents who resided in the facility and received meals from the facility kitchen. Findings included:- On 09/15/25 at 11:00 AM, a review of the noon meal consisted of chicken breast with seasoned tomatoes, squash, fortified mashed potatoes, buttered noodles, and cake.On 09/15/25 at 11:30 AM, observation revealed Dietary Staff (DS) BB in the kitchen preparing the noon meal. On 09/15/25 at 10:50 AM, DS BB verified she was not a Certified Dietary Manager (CDM). DS BB stated she had enrolled and started the dietary certification classes.On 09/16/25 at 10:07 AM, Administrative Nurse D verified DS BB had no dietary manager certification but had enrolled and started the dietary certification classes. The facility's Dining Services Manager Roles and Responsibilities Policy, undated, documented the following qualifications of the dining services manager: should be considered: Certified…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-09-16 · tag F0802 — failed to prepare enough nourishing food — patternProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 48 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide an adequate number of dietary staff to serve the residents, who received their meals in the dining room.Findings included:- On 09/15/25 at 11:45 AM, observation in the kitchen revealed Dietary Manager (DM) BB had tempered the food items on the steam table and was ready to serve the residents' food. Observation revealed several residents sat at dining room tables waiting for their noon meal.On 09/15/25 at 12:15 PM, staff came to the serving window and notified DM BB that they were ready to serve residents' food. Observation revealed DM BB completed serving at 01:00 PM.On 09/15/25 at 11:45 AM, DM BB stated the scheduled time for the noon meal was 11:30 AM. DM BB stated she could not start serving residents in the dining room their noon meal until staff were available in the dining room to serve food. DM BB stated she only had one dietary aide who was responsible for placing drinks on trays and other items needed that were not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-09-16 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — the official record, unedited, may be distressing
The facility had a census of 48 residents. Based on observation, interview, and record review, the facility failed to cover clean linen and clothing when transporting through the facility to prevent potential contamination, which could lead to infection. Findings included: - On 09/14/25 at 12:30 PM, Housekeeping Staff U took an uncovered laundry cart with clean resident clothing hanging up and linens on the shelf through the facility to the southeast hall.On 09/15/25 at 11:55 AM, Housekeeping Staff V verified staff were to cover residents' personal clothing when transporting it to their room. On 09/15/25 at 01:00 PM, Administrative Nurse D staff should cover the residents' clothing when taking through the hall to their room. The facility's Handling Clean Linen policy, dated 06/2025, stated linen could become contaminated from environmental contaminants. The policy stated clean linens should be delivered to resident care units on covered carts with the covers down.
- Potential for harm · Dcited before2025-09-16 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — the official record, unedited, may be distressing
The facility had a census of 48 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility staff failed to treat Resident (R) 16 with dignity at the dining table when Certified Nurse Aide (CNA) P stated, Here is your bib, and placed a clothing protector on R16. Findings included:- On 09/14/25 at 11:32 AM, during the noon meal, R16 sat at the dining room table. CNA P brought a clothing protector to her table, stated, Here is your bib, and placed the clothing protector on R16.On 09/16/25 at 11:18 AM, Administrative Nurse D stated she would expect staff to offer a resident a clothing protector at meals, and staff should not call it a bib.The facility's Promoting/Maintaining Resident Dignity Policy, revised 01/01/20, documented that it was the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity, as well as care for each resident in a manner and in an environment that maintains or enhances the resident's quality of life by recognizing each resident's individuality.
- Potential for harm · D2025-09-16 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 48 residents. The sample included 12 residents, with three residents reviewed for accommodation of needs. Based on record review, observation, and interview, the facility failed to accommodate Resident (R) 31's needs when they failed to ensure R31's walker could safely fit into the bathroom after her admission to the facility. This deficient practice placed R31 at risk for falls as she would leave her walker outside the bathroom door and furniture walk (using the sink for support) in the bathroom to use the toilet and wash her hands.Findings included:- R31's Electronic Medical Record (EMR) documented diagnoses of cellulitis (skin infection caused by bacteria) of the lower extremities, osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), polyneuropathy (a general term for peripheral nervous system disorders that impact nerve function in multiple areas of the body), and hypertension (high blood pressure).The admission Minimum Data Set, dated 09/09/25, documented R31 had a Brief Interview for Mental Status…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-16 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 48 residents. The sample included 12 residents, with one reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide a bed hold notice, as required, to Resident (R) 4 or their representative upon discharge from the facility. Findings included:- R4's Electronic Medical Record documented diagnoses of sepsis (life-threatening systemic reaction that develops due to infections which cause inflammation throughout the entire body), anxiety (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), seizures (violent involuntary series of contractions of a group of muscles), and a history of sudden cardiac arrest.R4's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS documented R4 was dependent on staff for all activities of daily living. R4's medical record documented she had been…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-16 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 48 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to review or revise Resident (R) 5's care plan with new effective interventions after each fall.Findings included: - R5's Electronic Medical Record documented diagnoses of anxiety disorder (mental or emotional disorder characterized by apprehension, uncertainty, and irrational fear), dementia (progressive mental disorder characterized by failing memory, and confusion), and cerebral infarction (stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). R5's admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of seven, indicating severely impaired cognition. The MDS documented R5 was dependent on staff for activities of daily living, including mobility, and had no falls since admission.R5's Fall Care Area Assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-16 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 48 residents. The sample included 12 residents, with three residents reviewed for Activities of Daily Living (ADL). Based on record review, observation, and interview, the facility failed to ensure Resident (R) 31 was showered/bathed according to her preference, twice a week. Findings included:- R31's Electronic Medical Record (EMR) documented diagnoses of cellulitis (skin infection caused by bacteria) of the lower extremities, osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), polyneuropathy (a general term for peripheral nervous system disorders that impact nerve function in multiple areas of the body), and hypertension (high blood pressure).The admission Minimum Data Set (MDS), dated 09/09/25, documented R31 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R31 required supervision/touching or set-up help for all ADLs. The MDS documented R31 used a walker for locomotion. The MDS documented R31 received scheduled pain medication, as needed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 48 residents. The sample included 12 residents, with five residents reviewed for falls, supervision, and safety. Based on record review, observation, and interview, the facility failed to provide a safe environment with appropriate supervision to prevent falls for Resident (R) 46 and R5.Findings included:- R46's Electronic Medical Record (EMR) documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), arthritis (inflammation of a joint characterized by pain, swelling, redness and limitation of movement), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), abnormalities of gait and mobility, and a chronic non-pressure wound to the right foot. The Quarterly Minimum Data Set (MDS), dated 07/29/25, documented R46 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R46 required partial to moderate assistance for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 17 citations
- Potential for harm · Dcited before2024-12-17 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 34 residents. The facility identified 11 residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care). Based on record review, observation, and interview, the facility failed to ensure staff implemented targeted gown and glove use during the high-contact care of a resident with a wound infection during a dressing change. This deficient practice placed the resident at risk for infectious diseases. Findings included: - On 12/17/24 at 10:30 AM, Licensed Nurse (LN) G and Certified Nurse's Aide (CNA) M entered R1's room to perform a dressing change to the resident's buttocks. LN G and CNA M did not don a gown for the dressing change. LN G and CNA M entered R1's room, donned gloves only, and performed the dressing change. CNA M held R1 over to her left side while LN G cleansed the wound, cut the dressing to fit the wound, and then covered the wound with a bordered dressing. R1 did complain of pain during the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-13 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 58 residents. The sample included three residents, with three reviewed for abuse. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 2 remained free from misappropriation of her property. This placed the resident at risk for ongoing misappropriation and impaired psychosocial well-being. Findings included: - The Electronic Medical Record (EMR) for R2 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), pain, hypertension (high blood pressure), and weakness. The admission Minimum Data Set (MDS) dated [DATE] documented a resident interview where R2 indicated choosing her own clothes, and taking care of her personal belongings or things was very important to her. The Quarterly MDS dated 08/15/24 documented R2 had moderately impaired cognition. R2 required supervision with upper body dressing and personal hygiene. R2 required partial assistance with toileting, mobility, lower body…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-13 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 58 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to ensure adequate infection control measures for Resident (R) 1 during wound care, when staff did not change her gloves after she cleansed the wound. This placed the resident at risk for continued wound infection and complications. Findings included: - The Electronic Medical Record (EMR) for R1 documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (high blood pressure), open lesion (wound or injury), and cellulitis of the foot (skin infection caused by bacteria). The Quarterly/Medicare 5 Day Minimum Data Set (MDS), dated [DATE], documented that R1 had intact…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-02-05 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 47 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the 47 residents who resided in the facility and received meals from the facility kitchen. This placed the residents at risk for impaired nutrition. Findings included: - On 01/30/24 at 08:30 AM, observation revealed Dietary Staff BB was in the kitchen and oversaw the preparation of the breakfast meal. On 01/30/24 at 08:35 AM, Dietary Staff BB verified she was not a certified dietary manager. On 01/30/24 at 09:00 AM, Administrative Staff A verified Dietary Staff BB had no dietary manager certification. The facility's Director of Food and Nutrition Services policy, dated 2021, stated the director of food and nutrition services is responsible for all aspects of the food and nutrition services department including but not limited to food safety, cost management, and meeting nutritional needs of the residents. The director of food services is to be a certified dietary manager. The facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-02-05 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 47 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure the refrigerator seals were intact and ailed to use sanitation strips for the three-compartment sink. This placed the residents at risk for foodborne illness. Findings included: - On 01/31/24 at 08:30 AM, observation of the kitchen revealed a #1 two-door refrigerator with door seals peeling off. Further observation revealed #2 two-door refrigerator with door seals peeling off both doors. On 01/31/24 at 08:45 AM, observation revealed a three-compartment sink with water in the sink. Further observation revealed a cork bulletin board hanging above the sink with large pieces of the cork board falling into the sink. On 01/31/24 at 08:50 AM, observation revealed a plastic baggie hanging on the cork bulletin board above the three-compartment sink which contained sanitation strips with an expiration date of 08/01/22. On 01/31/24 at 08:50 AM, Dietary Staff (DS) BB verified refrigerators #1 and # 2 with door seals peeling off. DS BB…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-02-05 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 47 residents. The sample included 12 residents. Based on record review and interview, the facility lacked evidence the required infection preventionist attended the Quality Assessment and Assurance (QAA) Committee quarterly meetings. This placed the residents who resided in the facility at risk for decreased quality of care. Findings included: - On 02/05/24 at 10:45 AM, the facility's Quarterly Quality Assurance Performance Improvement (QAPI) Meeting Attendance Sheets lacked evidence the infection preventionist attended the June 2023, September 2023, and December 2023 meetings. On 02/05/24 at 12:33 PM, Administrative Nurse D verified the lack of an infection preventionist signature on the quarterly meetings sign-in sheets and stated the facility had not employed an infection preventionist at the times of the quarterly meetings. The facility's Quality Assurance Process Improvement Plan (QAPI) documented the purpose of the QAPI was to provide excellent quality care and services to the residents. The QAPI committee would meet monthly to report and discuss…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-05 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 47 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to clean the dining tables and chairs to provide a comfortable homelike environment in the dining room. This placed the residents who ate meals in the dining room at risk for an unsanitary, non-homelike environment. Findings included: - On 01/30/24 at 11:30 AM, observation of the lunch meal in the dining room included nine dining tables. Further observation revealed large amounts of dried brown, yellow, and green particles on all the edges of each dining table. Further observation revealed dried particles on the dining table legs and all 15 dining chairs. On 01/30/24 at 11:50 AM, observation revealed two residents placed napkins across the table on top of the dried particles before they received their meal plates. One female resident stated, I wish they would clean off these tables. On 01/31/24 at 09:30 AM, observation revealed a housekeeper in the dining room.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-02-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 47 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to ensure an environment free from accident hazards with staff left one of three medication carts and a treatment cart unsupervised and unlocked by the dining area and failed to secure a wall cabinet in the [NAME] shower room. This placed the seven cognitively impaired, independently mobile residents at risk for preventable accidents or injuries. Finding included: - On 01/30/24 at 08:10 AM, observation revealed the [NAME] shower room door open with an unlocked unsupervised wall cabinet containing the following items: One 1.5-ounce container of tolnaftate antifungal (medication used to treat skin infections) 1% powder whose label read avoid contact with eyes, nose, or mouth. Four disposable razors. Two 11-ounce cans of fresh scent shaving cream. Two 11-ounce containers of Selsun blue antidandruff shampoo/selenium sulfide (a medication used to treat several skin conditions) whose label read avoid contact with eyes. Two 12.5-ounce…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-05 · tag F0908 — failed to keep essential equipment working — patternKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 47 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure the kitchen's plate warmer and prep sink were in safe and operable condition. This placed the residents who received their meals from the kitchen at risk of receiving cold food and the inoperable prep sink created the risk for food borne illness. Findings included: - On 02/01/24 at 11:50 AM, observation revealed the plate warmer in the kitchen was not working. The small kitchen prep sink was also not working. On 02/01/24 at 11:50 AM, Dietary Manager (DM) BB verified the plate warmer was not working and stated it had not been working for some time. DM BB also verified the small kitchen prep sink also not working. On 02/01/24 at 01:00 PM, Maintenance Director (MD) V stated he was unaware of the issue with the plate warmer. MD V stated he was aware of the kitchen prep sink not working. The facility's Preventative Maintenance Program, revised 01/09/24, documented a preventative maintenance program would be developed and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-05 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 47 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to treat two unsampled residents with dignity when staff administered Resident (R) 21's Flonase (allergy medication) nasal spray and R26's dorzolamide timolol (medication used to reduce pressure in the eye) eye drops at the dining room. This placed the residents at risk for an undignified experience. Findings included: - On 01/31/24 at 07:55 AM, observation revealed Licensed Nurse (LN) G administered R21's Flonase, 50 micrograms (mcg), nasal spray at the dining room table with 14 other residents present and able to view the procedure. On 01/31/24 at 08:00 AM, observation revealed LN G administered R26's dorzolamide timolol eye drop at the dining room table with 17 residents present and able to view the procedure. On 02/05/24 at 12:30 PM, Administrative Nurse D stated if a resident was in the dining room and staff needed to administer an eye drop or nasal spray, staff should take the resident to a private area to administer them. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-05 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 47 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to handle soiled linen in a sanitary manner to prevent the development and transmission of communicable diseases and infections. This placed the affected resident at risk for infection. Findings included: - On 01/31/24 at 08:00 AM, observation revealed Certified Nurse Aide (CNA) M walked out of Resident (R) 34's room. Further observation revealed CNA M carried unbagged soiled linen, walked to the end of the south hallway, and then placed the soiled linen in a soiled linen barrel. On 01/31/24 at 08:15 AM, observation revealed CNA M walked out of R 21's room. Further observation revealed CNA M carried unbagged soiled linen, walked to the end of the south hallway, and then placed the soiled linen in a soiled linen barrel. On 02/01/24 at 07:45 AM, observation revealed CNA N walked out of R 31's room. Further observation revealed CNA N carried unbagged soiled linen, walked to the end of the north hallway, and then placed the soiled linen in a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-29 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 38 residents with three residents reviewed for abuse and neglect. Based on record review, observation and interview, the facility failed to ensure residents remained free from verbal abuse/mistreatment. On 08/26/23 at approximately 06:00 PM, Resident (R) 1 was assisted to the toilet by a Certified Nurse's Aide (CNA). R1 placed her call light on and heard her door open to her room. R1 asked if whoever had entered the room was going to help her off of the toilet. CNA M yelled at R1, I'm not here to help you. R1's roommate, R2, told CNA M R1's call light had been on for fifteen minutes and she needed help off the toilet. CNA M yelled at R2 to not tell her what to do. CNA M left the room. R1 went to the nurse's desk to get a cigarette and CNA M continued to engage R1 in verbal altercation. This deficient practice placed R1 at risk for psychosocial impairment. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of major depressive disorder (major…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-29 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 38 residents with three reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on record review, interview and observation, the facility failed to put interventions into place immediately upon identifying an unavoidable pressure ulcer. The facility further failed to involve the registered dietician in a timely manner in order to obtain nutritional interventions to promote wound healing for Resident (R) 2's coccyx (tail bone area). This deficient practice placed R2 at risk for delayed wound healing. Findings included: - R2's Electronic Medical Record (EMR) documented R2 had diagnoses of major depressive disorder (major mood disorder), cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting the left non-dominant side, and hypertension (high blood pressure). The Quarterly Minimum Data Set…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-09-26 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 39 residents. Based on observation, record review, and interview the facility failed to provide a backflow device (prevent unwanted flow of water in the reverse direction) or a two-inch air gap for the drainage system of the kitchen ice machine, used by the 39 residents who resided in the facility. This placed the affected residents at risk to receive contaminated ice. Findings Included: - On 09/21/22 at 10:59 AM, observation revealed a plastic flex-hose drain device extended from the back of the ice machine, inserted into a rigid plastic drainpipe that extended along the floor and inserted into a floor drain under the dishwasher. Continued observation revealed the ice machine drainage system had no backflow device or two-inch air gap at the rigid plastic drainpipe or floor drain. On 009/21/22 at 11:56 AM, Maintenance Staff U verified the ice machine drainage system did not have a backflow device, or two-inch air gap to prevent possible backflow contamination into the ice supply. The facility's Preventative Maintenance, policy, dated 10/25/19, recorded…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-09-26 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 39 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to monitor and adhere to cleaning and disinfecting shared equipment which consisted of a digital thermometer, placing the residents at risk for infection. Findings included: - On 09/20/22 at 08:00AM, upon entrance into the facility observation revealed a sign in sheet to document entrance and temperature for all who entered into the facility, and a digital thermometer. Further observation revealed no supplies for disinfecting or cleaning the thermometer. On 09/20/22 at 10:10AM, observation revealed two visitors entered the facility. Further observation revealed a staff member assisted the visitors with completing the sign in sheet at the front entrance, completed the visitors' temperature with the digital thermometer and did not clean the thermometer after use. On 09/21/22 at 7:00AM, observation continued to reveal no supplies were available to clean the digital thermometer. On 09/21/22 at 08:40AM, Administrative Staff A and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-09-26 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 39 residents. The sample included 13 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to place a stop date on an as needed (prn) psychotropic (medication used to treat mental health disorders) medication for Resident (R) 27. This placed the resident at risk for unnecessary medications and related complications. Findings included: - R27's Electronic Medical Record (EMR) documented R27 had diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). R27's Quarterly Minimum Data Set (MDS), dated [DATE], documented R27 had a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderately impaired cognition. The MDS documented the resident required extensive staff assistance with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-09-26 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 39 residents. The sample included 12 residents. Based on observation, record review, and interview, facility staff failed to place an open date on Resident (R) 19's Levemir (long acting insulin-a medication that works by lowering levels of glucose (sugar) in the blood) flex pen (device used to inject insulin). This placed the resident at risk for receiving an expired and ineffective dose of insulin. Findings included: - On [DATE] at 08:50 AM, observation of the medication cart revealed R19's Levemir flex pen without an open date or discard date. On [DATE] at 8:50 AM, Licensed Nurse (LN) G verified the above finding and stated night shift administers R19's Levemir. LN G stated the insulin should be labeled with an open date; LN G discarded the insulin pen in the sharps container on the medication cart. On [DATE] at 09:42 AM, Administrative Nurse D stated she expected staff to label open insulin pens with the date opened and staff initials, and place in a plastic container in the top…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$20,323 in federal fines across 1 penalty.
- $20,323 — penalty dated 2025-09-16
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to RECOVER-CARE HEALTHCARE — 27 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.4 | -0.4 vs chain |
| Health inspection | 2 of 5 | 2.5 | -0.5 vs chain |
| Staffing | 2 of 5 | 2.4 | -0.4 vs chain |
| Quality measures | 2 of 5 | 3.1 | -1.1 vs chain |
The other 26 homes this chain runs (chain average 2.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| MIDWEST SNF HOLDINGS LLC | Organization | DIRECT OWNERSHIP INTEREST | since 02/28/2025 |
| MRCMM II LLC | Organization | DIRECT OWNERSHIP INTEREST | since 02/28/2025 |
| SINGER, MARK | Individual | DIRECT OWNERSHIP INTEREST | since 02/28/2025 |
| BHNV 2 LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 02/28/2025 |
| KAMNA HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 02/28/2025 |
| KANSAS SNF HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 02/28/2025 |
| MAD FAMILY HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 02/28/2025 |
| NATR TRUST | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 02/28/2025 |
| NZM HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 02/28/2025 |
| RARMNA HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 02/28/2025 |
| RATR TRUST | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 02/28/2025 |
| RECOVER-CARE HEALTHCARE LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 02/28/2025 |
| RNR HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 02/28/2025 |
| WETR TRUST | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 02/28/2025 |
| GOLDSTEIN, AVROHOM | Individual | INDIRECT OWNERSHIP INTEREST | since 02/28/2025 |
| HALBERSTAM, MIRIAM | Individual | INDIRECT OWNERSHIP INTEREST | since 02/28/2025 |
| HALBERSTAM, MOSHE | Individual | INDIRECT OWNERSHIP INTEREST | since 02/28/2025 |
| MARGULIES, ZISHA | Individual | INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | since 02/28/2025 |
| MRC SNF MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/01/2021 |
| KLECAN, KURTIS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/28/2025 |
| SWAGERTY, SWEDE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/17/2025 |
| WHITE, DANIELLE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 02/28/2025 |
CMS files one row per role, so the 33 rows in the source record cover these 22 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
14 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $588K paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in KS
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Kansas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175246. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-16, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.