Spring View Manor Healthcare And Rehabilitation
412 S 8th Street, Conway Springs, KS 67031 · For profit - Limited Liability company · 45 certified beds · (620) 456-2285 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing 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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 held steady at 3 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 | 15.4% | 17.9% | 15.4% | typical |
| Long-stay residents who lose too much weight | 1.6% | 4.9% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.7% | 1.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.4% | 2.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 2.8% | 6.5% | 6.5% | better |
| 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 | 1.3% | 4.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 16.5% | 16.2% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 27.1% | 23.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 73.8% | 95.5% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 3.0% | 4.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 29.5% | 22.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.6% | 18.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.2% | 1.9% | 1.4% | worse |
| Short-stay residents rehospitalized after admission | 15.3% | 22.4% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 9.7% | 11.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.37 | 1.80 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.10 | 2.13 | 1.80 | better |
‡ 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.
48.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 34 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.31 therapist hours per resident per day in 2026Q1 — more than 50% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | 48.2%CMS range 33.7–64.3 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.3%CMS range 6.5–15.2 | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 20.8% | 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 | 0.0% | 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 | 4.2% | 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 | 6.7%CMS range 3.3–13.6 | 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 45 beds and averages 40.9 residents a day — about 91% occupied, or roughly 4 beds typically open. It runs fairly full. 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 3.53 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.69 is at or above 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 3.22 hrs/resident/day on weekends vs 3.66 on weekdays — 12% thinner on weekends. RN hours go from 0.66 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%.
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.
17 citations, most serious first. The 10 most serious are shown; the remaining 7 are one tap away and print in full.
- Potential for harm · F2026-03-17 · 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 reported a census of 40 residents with one kitchen. Based on observation, interview, and record review, the facility failed to provide sanitary conditions for food storage and preparation to prevent the potential spread of foodborne illness to the residents of the facility. Findings included:- Initial tour of the facility kitchen on 03/15/26 at 08:05 AM with Dietary Staff (DS) EE, revealed the following areas of concern:Three open plastic bags of food in the freezer have ice crystals formed directly on the food items inside the bags.One unsealed bag of meat. One package of opened cheese. During an observation on 03/16/26 at 11:17 AM, DS EE checked the dishwasher water temperature with a thermometer. The thermometer recorded the dishwasher's water temperature at 103 degrees Fahrenheit (F). During an interview with DS EE on 03/16/26 at 11:20 AM, DS EE said the water temperature of the dishwasher should be 120 degrees F. to properly disinfect/sanitize dishware/cookware in the dishwasher. During an observation on 03/15/26 at 11:36 AM, DS CC carried a resident's meal plate…
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 · F2026-03-17 · tag F0947 — failed to train nurse aides adequately — widespreadEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — the official record, unedited, may be distressing
The facility reported a census of 40 residents. Based on interview and record review, the facility failed to develop, implement, and permanently maintain an in-service training program for Certified Nurse Aide (CNAs) with the required topics and no less than 12 hours per year for two out of five staff reviewed.Findings included:- On 03/16/26 at 12:44 PM, review of training records for five Certified Nurse Aides (CNAs) employed by the facility for more than one year revealed two CNAs had less than 12 hours of documented in-service training for the previous 12 months. CNA P, with a start date of 12/20/23, had eight hours of documented training, and CNA Q, with a start date of 07/22/24, had seven hours of documented training. On 03/17/26 at 09:18 AM, Administrative Nurse E confirmed that all CNAs were required to have 12 hours of training annually and stated that there were no records of additional training for those CNAs. The facility did not provide a policy.
- Potential for harm · D2026-03-17 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 40 residents. The sample included 12 residents with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Lability notices. Based on record review and interviews, the facility failed to provide form CMS-10055 Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-Coverage (ABN- which included the estimated cost for continued services) to the resident or their representative for Resident (R) 6 and R25.Findings included: - R6's Electronic Medical Record (EMR) documented a Medicare Part A episode beginning on 09/18/25 and ending on 10/20/25. R6 remained in the facility for custodial care. R6's EMR lacked evidence that the ABN was provided. Review of the R25's EMR documented a Medicare Part A episode that began on 10/25/25 and ended on 12/24/25. R25 remained in the facility for custodial care. R25's EMR lacked evidence that the ABN was provided. On 3/17/26 at 07:45 AM, Social Service Staff X stated she was not aware she needed to complete and issue the ABN. She reported she discussed this with 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 · D2026-03-17 · 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
The facility reported a census of 40 residents. The sample included 12 residents with four residents reviewed for hospitalization. Based on interview and record review, the facility failed to provide Resident (R) 50 with a written notification of transfer to the resident and/or his representative as soon as practicable and failed to send a copy of that notification to the ombudsman.Findings included:-R50's Electronic Medical Record (EMR) revealed a diagnosis of obesity (excessive body fat), dependence on supplemental oxygen, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and skin cancer. R50's Nurse's Note dated 12/11/25 at 05:34 PM documented R50 was short of breath, coughing up yellow sputum, and had an oxygen saturation (percentage of oxygen in the blood) level of 88 percent (%). New medication orders were given at that time, as well as lab orders and an order for a mobile chest X-ray.R50's Nurse's Note dated 12/11/25 at 06:21 PM documented the nurse left a message for 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 · D2026-03-17 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 reported a census of 40 residents and one kitchen. Based on observation, interview, and record review, the facility failed to ensure staff served meals at safe and appetizing temperatures. The facility also failed to follow the recipe of pureed green beans, which altered the nutritive content. Findings Included:- During an observation on 03/16/26 at 11:08 AM, Dietary Staff (DS) EE added tap water to the green beans during the puree process of the green beans. Immediate review of the facility recipe for pureed green beans revealed that if the puree consistency needed to be thinned, the staff were to gradually add an appropriate hot liquid such as broth, gravy, milk, or reserved cooking liquid.During an observation on 03/16/2026 at 11:35 AM, DS EE handed the cooked pureed spaghetti to DS BB, who then took the cooked pureed spaghetti to a resident in the dining room. Upon prompting/request, DS BB obtained a temperature of the pureed spaghetti and reported it was 127 degrees Fahrenheit (F).During an…
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 before2026-03-17 · 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 40 residents. The facility identified 10 residents on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to ensure Resident (R) 37 and R5's nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) masks were stored in a sanitary manner when not in use. The facility also failed to ensure staff wore the required personal protective equipment (PPE) for EBP and sanitized hands when doing direct care.Findings included:-Observation on 03/15/26 at 09:01 AM revealed Certified Medication Aide (CMA) R & Certified Nurse Aide (CNA) N applied gloves but did not perform hand hygiene when entering R8's room. CNA N raised the bed and grabbed the trash can around the rim of the can. CMA R opened R8's incontinence brief and wiped R8's peri area. CNA N took a wipe and wiped R8's peri area. CNA N removed R8's soiled brief…
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 before2026-03-17 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 40 residents. The sample included 12 residents with five reviewed for immunization status. Based on record reviews, and interviews, the facility failed to offer or obtain informed declinations, consent, or a physician-documented contraindication for the influenza (highly contagious viral infection that attacks the lungs, nose, and throat and can be deadly in high-risk groups) vaccination for Resident (R) 28.Findings included:- On 03/15/26, R28's clinical record revealed he was admitted on [DATE]. The Electronic Medical Record (EM) under the Immunization tab lacked documentation of whether the influenza vaccination was offered or declined, and lacked documentation of a historical administration or physician-documented contraindication. The facility provided a declination for the annual influenza vaccination dated 03/16/26.On 03/16/26 at 03:50 PM, Administrative Nurse E, the facility's Infection Preventionist, stated she was the person responsible for tracking immunizations. She…
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 · F2024-05-02 · tag F0730 — widespreadObserve each nurse aide's job performance and give regular training.
What the surveyor found here — the official record, unedited, may be distressing
The facility reported a census of 34 residents. Based on record review and interview, the facility failed to ensure four out of five Certified Nurse Aides (CNA) who were employed over a year, and Certified Medication Aides (CMA/CNA) reviewed, received annual evaluations as required. Findings included: - Review of the personnel file for five certified Nurse Aides (CNA) and Certified Medication Aides (CMA) employed over one year, revealed the following areas of concern: CNA N, with hire date 02/10/21, lacked an annual evaluation. CNA M, with hire date 02/10/21, lacked an annual evaluation. CNA O, with hire date 09/03/22, lacked an annual evaluation. CMA R, with hire date 01/13/20, lacked an annual evaluation. Interview on 05/01/24 at 03:22 PM, with consultant GG revealed she would expect staff to have evaluations annually. The facility policy Evaluation Process, implemented 12/01/19, instructed staff to review the work performance of employees with a formal written evaluation annually. The facility failed to ensure certified staff received annual evaluations as required.
- Potential for harm · F2024-05-02 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 34 residents. Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS i.e., Payroll Base Journal (PBJ), related to licensed nursing licensed and certified nursing staffing information when the facility failed to accurately report weekend staffing for the second quarter 2023 January through March and fourth quarter 2023 July through September 2023. Findings included: - Review of the nursing staff schedule for the second quarter 2023 January through March 2023 and fourth quarter 2023 July through September, revealed multiple changes/additions in staffing for the weekends with agency staff utilized. Review of the PBJ Staffing Data Report, for the second quarter 2023, revealed the PBJ triggered for Excessively Low weekend Staffing. Review of the PBJ Staffing Data Report, for the fourth quarter 2023,…
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 before2024-05-02 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 34 residents with five residents reviewed for immunizations. Based on interview and record review, the facility failed to ensure staff provided education for informed decision making for the 2023 influenza vaccine for two of the five residents, Resident (R)21 and R11. The facility failed to ensure one of the five residents received education for informed decision making for the pneumococcal vaccine, R21. The facility failed to ensure three of the five residents received education for informed decision making for the Covid-19 vaccination. Findings included: - Review of Resident (R)21's electronic medical record revealed the resident admitted to the facility 01/19/24. The Immunization tab documented the last influenza vaccine as 12/12/22 and the last covid-19 vaccine as 12/03/21. The medical record lacked documentation of pneumonia vaccine status. The medical record lacked evidence of education provided for informed decision making for receipt/declination for the vaccines. Review of R11's electronic medical record revealed the resident admitted to 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.
Show the remaining 7 citations
- Potential for harm · D2024-05-02 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 34 residents with 12 residents selected for review, which included three residents reviewed for activities of daily living (ADL's). Based on observation, interview, and record review, the facility failed to provide personal grooming for one of the three, Residents (R)10, reviewed for activities of daily living. Findings included: - Review of Resident (R)10's undated Physician Order Summary revealed diagnoses that included hemiplegia (paralysis on one side of the body,) hemiparesis (muscular weakness on one side of the body,) cerebral vascular accident (CVA/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,) and major depressive disorder (major mood disorder.) The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of seven, which indicated severe cognitive impairment. The resident had functional impairment on one…
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 · D2024-05-02 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 34 residents with 12 residents selected for review. Based on interview and record review, the facility failed to obtain laboratory values in a timely manner for one of the 12 Residents (R)4, and failed to administer medications according to physician instructions for one of the 12 residents, (R)29. Findings Included: - Review of Resident (R)4's undated Physician Order Sheet revealed diagnoses that included chronic respiratory and heart failure, diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin ) and kidney failure. On 04/10/24, a licensed nursing noted documented staff notified the physician that R29 had nausea and vomiting for three days. The physician instructed staff to obtain a Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) on 04/11/24. A nurse note, dated 04/11/24, documented licensed nursing staff notified the physician that the resident continued with nausea and vomiting, and the facility failed to obtain the CBC and CMP. On 04/12/24 the facility obtained 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 before2024-05-02 · 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 reported a census of 34 residents which included 12 residents selected for review. Based on observation, interview, and record review, the facility failed to ensure one of the 12 Residents, Resident (R) 1, received sanitary tube feeding technique, and staff performed hand hygiene prior to insulin administration for one of two residents (R)9 related to insulin administration to prevent possible infections. Findings included: - Review of Resident (R)1's electronic medical record revealed diagnoses that included cerebral vascular accident (CVA, 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) and swallowing disorder. Observation on 05/01/24 at 08:21 AM, revealed Licensed Nurse (LN) G prepared to administer R1's medications through her percutaneous gastrostomy tube (PEG a tube that enters the stomach through a surgical opening in the resident's abdomen for the administration of medications and nutrition when a person is unable to swallow). The syringe for attaching to 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 · D2022-11-09 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 reported a census of 28 residents with 13 selected for review. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for one of the residents, Resident (R)9 for use of CPAP (continuous positive airway pressure)/BiPAP (bi-level positive airway pressure) equipment. Findingsincluded: - The Medical Diagnosis tab for Resident (9) included diagnoses of sleep related non-obstructive alveolar (air sacs where the lungs and the blood exchange oxygen and carbon dioxide during the process of breathing in/out), hypoventilation (abnormally slow rate of breathing resulting in increased amount of carbon dioxide in the blood), and obstructive sleep apnea (disorder of sleep characterized by periods without respirations). The admission Minimum Data Set (MDS) dated [DATE] revealed R9 admitted to the facility on [DATE]. He had a Brief Interview of Mental Status (BIMS) score of 15, indicating cognitively intact. He required oxygen use and CPAP/BiPAP while a resident…
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 · D2022-11-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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 reported a census of 28 residents with 13 selected for review, including one reviewed for respiratory care services. Based on observation, interview, and record review, the facility failed to change out oxygen tubing per physician order and failed to obtain physician order for use, settings, and care of one of the resident's, Resident (R)9's use of his CPAP (continuous positive airway pressure)/BiPAP (bi-level positive airway pressure) equipment, which increased risk of R9 developing a respiratory infection. Findings included: - The Medical Diagnosis tab for Resident (9) included diagnoses of sleep related non-obstructive alveolar (air sacs where the lungs and the blood exchange oxygen and carbon dioxide during the process of breathing in/out), hypoventilation (abnormally slow rate of breathing resulting in increased amount of carbon dioxide in the blood), and obstructive sleep apnea (disorder of sleep characterized by periods without respirations). The admission Minimum Data Set (MDS) dated [DATE]…
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.
- No harm found · Ccited before2026-03-17 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 40 residents. Based on observation, interview, and record review, the facility failed to ensure the posted daily nurse staffing sheets included accurate and identifiable information to include actual staff hours, as required.Findings included:- During an observation on 03/16/26 at 08:36 AM, the daily staffing sheet hung on the wall near the nurse's station. The daily nurse staffing form for 03/16/26 was posted and lacked the actual hours worked per shift for licensed and unlicensed staff providing resident care.On 03/16/26 at 08:35 AM, Licensed Nurse (LN) G stated that the nurse does not change the time or add actual hours on the posted staffing sheet. An example is today, there was a staff member who was late, and he would not write anything on the sheet. The business office will do it later.On 03/16/26 at 08:47 AM, Administrative Nurse E stated she put the staff sheet out, and at the end of the week, the office put actual hours on the sheet. No actual hours are adjusted until then.On 03/16/26 at 12:12 PM, the daily nurse staffing form for 03/16/26…
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.
- No harm found · Ccited before2024-05-02 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
The facility reported a census of 34 residents. Based on interview and record review, the facility failed to ensure the daily staff posting contained actual hours worked as required. Findings included: - Review of the Daily Staff Postings from February 2024, March 2024, and April 2024, revealed lack of actual hours worked for staff. Interview, on 05/02/24 at 12:20 PM, with Administrative Staff A, revealed confirmed the facility lacked recording of the actual hours worked for staff on the daily staff postings. Administrative Staff A stated the business office documented the actual hours worked through a computer program and did not record the hours on the daily staff posting sheets. The facility lacked a policy for daily staff posting. The facility failed to ensure staff recorded the actual hours worked by staff on the daily staff posting as required.
“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
No federal fines in the current CMS record.
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 | 3 of 5 | 2.4 | +0.6 vs chain |
| Health inspection | 3 of 5 | 2.5 | +0.5 vs chain |
| Staffing | 2 of 5 | 2.4 | -0.4 vs chain |
| Quality measures | 4 of 5 | 3.1 | +0.9 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 |
| BHNV 2 LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 02/28/2025 |
| KAMNA HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 02/28/2025 |
| NZM HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 02/28/2025 |
| RECOVER-CARE HEALTHCARE LLC | Organization | INDIRECT OWNERSHIP INTEREST | 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 |
| MRC SNF MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/01/2020 |
| MARGULIES, ZISHA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 02/28/2025 |
| MCCUE, TAMARA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/20/2026 |
| SIFAH, NAANA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/20/2026 |
| STAPLETON, HEATHER | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 02/28/2025 |
| BHNV PROPERTY HOLDINGS 2 LLC | Organization | ADP OF THE SNF | since 02/28/2025 |
| KANSAS SNF HOLDINGS LLC | Organization | ADP OF THE SNF | since 02/28/2025 |
| MAD FAMILY HOLDINGS LLC | Organization | ADP OF THE SNF | since 02/28/2025 |
| NATR TRUST | Organization | ADP OF THE SNF | since 02/28/2025 |
| NZM PROPERTY HOLDINGS LLC | Organization | ADP OF THE SNF | since 02/28/2025 |
| RARMNA HOLDINGS LLC | Organization | ADP OF THE SNF | since 02/28/2025 |
| RATR TRUST | Organization | ADP OF THE SNF | since 02/28/2025 |
| RNR HOLDINGS LLC | Organization | ADP OF THE SNF | since 02/28/2025 |
| WETR TRUST | Organization | ADP OF THE SNF | since 02/28/2025 |
CMS files one row per role, so the 26 rows in the source record cover these 23 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.
16 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 $489K paid to related parties — landlords or management companies under common ownership — equal to about 16% 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.
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 175504. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-17, 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.