Flint Hills Care And Rehabilitation Center
1620 Wheeler Street, Emporia, KS 66801 · For profit - Limited Liability company · 50 certified beds · (620) 342-3280 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $22,048 in federal fines (most recent 2025-07-01)
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
- about 19% of its spending goes to commonly-owned related companies
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 | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 5 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 5 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 improved from 2 to 4 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 | 25.8% | 17.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 10.3% | 4.9% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.3% | 1.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.3% | 2.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 83.2% | 6.5% | 6.5% | check this† — see note marked dagger below the table |
| 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 | 2.5% | 4.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 13.1% | 16.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 21.2% | 23.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 93.8% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.3% | 4.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 28.9% | 22.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 3.7% | 18.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.2% | 1.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 61.5% | 73.8% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 10.9% | 22.4% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 8.0% | 11.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.93 | 1.80 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.04 | 2.13 | 1.80 | worse |
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.
‡ 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.
55.5% 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 33 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 72.5% 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 40 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 0.31 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 26% 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 | 55.5%CMS range 37.6–69.2 | 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 | 9.9%CMS range 5.8–16.6 | 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 | 72.5% | 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 | 62.5% | 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 | 67.5% | 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 | 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 | 4.3% | 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 | 6.1%CMS range 3.2–13.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.06 | 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 50 beds and averages 46.1 residents a day — about 92% 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 3.57 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.54 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 3.04 hrs/resident/day on weekends vs 3.78 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.69 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 49% 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.
31 citations, most serious first. The 12 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · G2025-07-01 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 44 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to administer scheduled pain medication and take action to manage severe pain for Resident (R)32. Additionally, the facility failed to re-order the scheduled pain medication and notify the provider when the pain medication was not available. As a result of the deficient practice, R32 experienced severe pain with ineffective pain relief for two days and had physical symptoms of abrupt withdrawal, including nausea and vomiting, related to the facility not administering the scheduled, physician ordered pain medication. This also placed R32 at risk for discomfort and further decline in her overall well-being.Findings included: - A review of the Electronic Health Record (EHR), documented R32 had diagnoses of osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) of the right hip, chronic pain, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational…
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 · G2024-02-27 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 44 residents with nine residents selected for review, including three residents reviewed for skin conditions. Based on record review and interview, the facility failed to provide appropriate treatment services for one Resident (R)7's pressure ulcer (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) at a Stage 3 (full thickness pressure injury extending through the skin into the tissue below), present on admission to her coccyx (area at the base of the spine) when they failed to obtain physician ordered treatment until seven days after admission to the facility, failed to assess the wound until three days after admission to the facility, failed to ensure R7 had a dressing replaced timely when soiled or absent, and failed to provide a pressure reducing device to the seat of her wheelchair until three days after admission. R7's pressure area deteriorated to 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 · E2025-07-01 · tag F0678 — failed to provide CPR when needed — patternProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
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 44 residents; the sample included 12 residents. Based on observation, interview, and record review, the facility failed to develop and implement a system to ensure the presence of at least one staff certified in cardiopulmonary resuscitation (CPR- an emergency lifesaving procedure performed when the heart stops beating) during transportation provided by the facility for residents who desired a Full Code status (full resuscitative measures). This deficient practice placed the residents at risk for decreased quality of care and inadequate resuscitative measures.Findings included:- Review of Certified Nurse Aide (CNA) /Transportation Aide's O's health care credentials revealed she lacked CPR certification. Review of the facility's Code Status Listing dated [DATE], revealed 24 of the 44 residents identified as Full Code (requesting to receive CPR in the event their heart stopped and/or breathing stopped). Review of the Transportation Schedule/Log, dated [DATE] through [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.
- Potential for harm · Ecited before2025-07-01 · 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 reported a census of 44 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to utilize 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) when providing catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care for Resident (R) 7. Additionally, the facility failed to provide adequate incontinence care (the management and support provided to individuals who experience involuntary loss of urine) for R40 and R34 when staff failed to complete proper hand hygiene and cleansing of the peri-area. The facility failed to store respiratory equipment in a sanitary manner for R32 and R20. The facility failed to provide personal protective equipment (PPE- gowns, face shields,/eyeglasses/goggles, and gloves) for the laundry staff to utilize when sorting soiled linens. These deficient practices had the potential to…
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 · D2025-07-01 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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 44 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to identify an elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff) as a potential neglect and report to the State Agency (SA) as required. This placed the resident at risk for neglect and impaired safety.Findings included:- Review of the Electronic Health Record (EHR) documented Resident (R)30 had diagnoses which included dementia (a progressive mental disorder characterized by failing memory and confusion), and mood disorder. R30 admitted to the facility on [DATE].R30's 09/15/24 Annual Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) of eight, which indicated moderately impaired cognition. The MDS documented R30 required maximal assistance for bathing, transfers, dressing, and toileting. The MDS documented R30 required moderate assistance with oral care, personal hygiene,…
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 · D2025-07-01 · 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 44 residents. The sample included 12 residents, with one resident reviewed for hospitalization. Based on interview and record review, the facility failed to provide a written bed hold policy and failed to issue written notification as soon as practicable for transfers for Resident (R) 32 This placed the resident at risk for impaired rights related to returning to the facility.Findings included:- Review of the Electronic Health Record (EHR), documented R32 had diagnoses of osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) of the right hip, chronic pain, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).R32's 02/01/25 Annual Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. The MDS documented R32 required supervision for bathing and was independent for all activities of daily living (ADL).R32's…
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 before2025-07-01 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 44 residents; 12 residents were sampled for review. Based on observation, interview, and record review the facility failed to ensure accurate Minimum Data Set (MDS) assessments for Residents (R) 18, R42, and R7 related to urinary continence and/or indwelling catheter (a tube inserted into the bladder to drain urine into a collection bag) and R7 for communication/sensory status. The deficient practice placed the affected residents at risk for impaired care due to unidentified care needs.Findings included:- R18's Electronic Health Records (EHR) documented diagnoses, which included neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying).R18's admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating cognitively intact. He had an indwelling catheter and was always continent (able to control bladder/urine flow).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 before2025-07-01 · 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 reported a census of 44 residents. The sample included 12 residents, with one reviewed for hearing aid use. Based on the interview and record review, the facility failed to ensure that dependent Resident (R) 7 received staff assistance in placing his hearing aids. This placed the resident at risk for social isolation, mental decline, and loss of independence. Findings included:- R7's Electronic Health Record (EHR) revealed diagnoses of conductive hearing loss and a need for assistance with personal care. R7's 08/30/24 Annual Minimum Data Set (MDS) documented that the resident had a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. The MDS documented R7 was dependent on staff for toileting, bathing, dressing, footwear, and personal hygiene. The MDS noted R7 had minimal difficulty with hearing, and R7 used hearing aids. The 09/06/24 Communication Care Area Assessment (CAA) documented R7 had a communication problem related to having difficulty understanding or making his needs known. The CAA noted R7 had hearing deficits…
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 before2025-07-01 · 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 reported a census of 44 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to provide adequate supervision to cognitively impaired, independently mobile Resident (R)30, identified as a high risk for elopement (when a cognitively impaired resident leaves the facility or safe area without staff knowledge or supervision). This placed the resident at risk for injuries, accidents, and further elopements. Findings included:- Review of the Electronic Health Record (EHR) documented R30 had diagnoses which included dementia (a progressive mental disorder characterized by failing memory and confusion), and mood disorder. R30 was admitted to the facility on [DATE].R30's 09/15/24 Annual Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) of eight, which indicated moderately impaired cognition. The MDS documented R30 required maximal assistance for bathing, transfers, dressing, and toileting. The MDS documented R30 required…
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 · D2025-07-01 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary 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 reported a census of 44 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observations, interview, and record review, the facility failed to notify the physician for blood sugars outside of the physician-ordered parameters for Resident (R) R29. The deficient practice placed the affected resident at risk for complications related to hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar)Findings included:- R29's Physician Orders dated 06/01/25 revealed the following diagnosis: type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin).R29's Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of six, indicating severely impaired cognition. The MDS noted R29 dependent upon staff for all activities of daily living (ADLs). The MDS did not indicate that injections or insulin were administered.R29's Quarterly MDS dated…
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 · F2024-06-25 · 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 45 residents. Based on observation, interview, and record review, the facility failed to ensure staff-maintained food on the steam table at a temperature of at least 135 degrees. Findings included: - Observation, on 06/24/24 at 12:30 PM, revealed Dietary Staff CC, obtained temperature of the food on the steam table as follows: Chicken paprikash had a temperature of 110 degrees Fahrenheit. Buttered egg noodles had a temperature of 120 degrees Fahrenheit. Interview on 06/24/24 at 12:30 PM, Dietary Staff CC reported she kept the food uncovered while she served the food to the residents. Dietary Staff CC obtained a temperature of the food when she removed it from the oven/cook top which registered 170 degrees Fahrenheit and placed it in the steam table pans but did not obtain the temperature as it was held on the steam table prior to serving the residents. Interview on 06/25/24 at 12:05 PM with Dietary staff BB, reported dietary staff had the exhaust fans on and the air conditioner yesterday (06/24/24) and this may have caused the lower food…
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 · D2024-06-25 · tag F0741 — failed to have staff trained for behavioral health — isolatedEnsure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
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 45 residents with nine residents selected for review, which included four residents reviewed for abuse, neglect, and exploitation. Based on observation, interview and record review, the facility failed to ensure staff were competent in interactions with aggressive behaviors for one Resident (R)9, with dementia. Findings included: - Review of Resident (R)9's medical record revealed diagnoses that included frontal temporal neurocognitive disorder( sometimes called frontotemporal dementia, which is damage to neurons in the frontal and temporal lobes of the brain which result in unusual behaviors, emotional problems, trouble communicating, difficulty with work, or difficulty with walking), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and moderate dementia (progressive mental disorder characterized by failing memory, confusion) with agitation (feeling of aggravation or restlessness brought on by a provocation or a medical…
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.
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- Potential for harm · F2024-02-27 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 44 residents. Based on observation, record review, and interview, the facility failed to have sufficient nursing staff at all times to meet the residents bathing needs and adequate call light response time. Findings included: - The Facility Assessment dated 11/09/23, revealed an average census of 41 to 43 residents with a staffing plan of two Licensed Nurses (LN) providing direct care and 12 nurse aides. An example documented revealed one LN for day shift from 05:00 AM to 05:00 PM and one LN for evening shift 05:00 PM to 05:00 AM, three CNA's on days and evenings, two CNA's on nights, two Certified Medication Aides (CMA) on days and one CMA on nights, a transportation CNA full time day shift and a restorative aide full time. The facility nursing schedule dated December 2023 revealed on day shift, 06:00 AM to 02:00 PM, the following days had two CNA's scheduled: 12/09/23, 12/11/23, 12/12/23, 12/13/23, 12/28/23, 12/29/23, and 12/31/23. On 12/16/23 there were 2.5 CNA's. Those dates lacked a restorative aide with exception on 12/29/23 from 09:00 AM to…
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 · D2024-02-27 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is 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 reported a census of 44 residents with nine residents selected for review, including three residents reviewed for bathing. Based on observation, interview, and record review, the facility failed to provide two of two non-dependent residents, Resident (R)2 and R8 adequate bathing. Findings included: - The Medical Diagnosis tab for Resident (R)2 included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and need for assistance with personal care. The admission Minimum Data Set (MDS) dated [DATE] assessed R2 with a Brief Interview of Mental Status (BIMS) score of 00 indicating severe cognitive impairment. R2 rejected care one to three days of the assessment period and required physical help of one staff for transfer only for bathing task. The Cognitive Loss/Dementia Care Area Assessment dated 09/29/23, revealed R2 had dementia, required cues for cares, and resisted assistance or redirection at times. The Quarterly MDS dated 12/22/23 revealed R2 had a loss 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.
- Potential for harm · Dcited before2024-02-27 · 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 44 residents with nine residents selected for review, including three reviewed for bathing. Based on observation, record review, and interview, the facility failed to provide adequate bathing for one dependent resident, Resident (R)6. Findings included: - The Medical Diagnosis tab for R6 included diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following 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) affecting right dominant side, stiffness in other specified joint, and contracture (abnormal permanent fixation of a joint or muscle) of muscle of right shoulder and right hand. The Annual Minimum Data Set (MDS) dated [DATE], assessed R6 with a Brief Interview of Mental Status (BIMS) score of nine, indicating moderate cognitive impairment, she did not reject care, and was totally dependent…
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 before2023-08-17 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 43 residents. Based on observation, interview and record review, the facility failed to provide infection surveillance tracking by organism to prevent the spread of infections. Findings included: - Review of the Infection Tracking logs from January 2023 through July 2023, revealed lack of microorganism identification from cultures (if obtained) on the logs to determine patterns for infections in the facility. Interview, on 08/17/23 at 3:00 PM, with Administrative Nurse D, confirmed the lack of identification of microorganisms for tracking. Administrative Nurse D stated the facility changed computerized programs, and failed to notice the organism identification did not transfer over to the Infection Tracking logs for determination of organism prevalence in the facility. The facility policy Infection Prevention and Control Program, revised 08/15/22, instructed staff to utilize a system of surveillance for prevention, identification, reporting, investigating, and controlling infections and communicable diseases for all residents. The facility failed to…
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 · E2023-08-17 · 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 43 residents. Based on interview and record review, the facility failed to ensure four Residents (R) 25, 40, 36 and 146 acknowledged receipt of COVID-19 vaccination information to make informed declination decisions as required. Findings included: - Review of Resident (R)25, R40, R36 and R 146, medical records revealed lacked COVID-19 declinations/receipt of vaccine information to make informed decisions. Interview, on 08/17/23 at 03:30 PM, with Administrative Nurse D, confirmed lack of declinations for these four residents. Administrative Nurse D stated she would expect staff to provide vaccine information and resident/legal guardian signature on the declination. The facility policy Vaccine Information Statements, dated 11/01/19, instructed staff to provide the most current vaccine information statement to the legal representative prior to administration and document in the medical record. The facility did not provide a policy for declinations of vaccines. The facility failed to ensure residents/legal guardians acknowledge receipt of COVID-19…
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 before2023-08-17 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 43 residents with 15 sampled for review. Based on observation, interview, and record review the facility failed to complete an accurate Minimum Data Set (MDS) for one Resident (R)8, regarding an indwelling urinary catheter. Findings included: - The Physician Order Sheet (POS), dated 08/01/23, documented the resident had a diagnosis of urinary retention (inability to pass urine). The admission Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed moderate impairment. He required extensive assistance of one staff for toileting and did not have an indwelling urinary catheter (a catheter (hollow tube) is inserted into the bladder to drain or collect urine). The resident was frequently incontinent of urine. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 06/12/23, inaccurately documented the resident had an indwelling urinary catheter. The indwelling catheter care plan, dated 06/06/23, instructed staff 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 · D2023-08-17 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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 43 residents with 15 selected for review. Based on observation, interview, and record review, the facility failed to ensure laboratory tests ordered by the physician were completed for two Residents (R)18 and R 34 and failed to ensure proper wheelchair positioning for one resident R2. Findings included: - Review of Resident (R)18's Physician Order Sheet, dated 07/27/23, revealed diagnoses included emphysema (long-term, progressive disease of the lungs characterized by shortness of breath, hypertension (elevated blood pressure), and alcohol dependence. The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with severe cognitive impairment. The resident received seven days of an antidepressant (a class of medications used to treat mood disorders and relieve symptoms of depression) during the seven days look back period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 11/09/22, assessed the resident with a long history of chronic alcohol abuse and 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 before2023-08-17 · 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 reported a census of 43 residents with 15 residents included in the sample, including three residents reviewed for accidents. Based on observations, interview and record review, the facility failed to safely transfer one dependent Resident (R)24, by failing to lock the brakes of her wheelchair before transferring her from her wheelchair to the toilet. Findings included: - The Physician Order Sheet (POS), dated 08/01/23, documented Resident (R) 24 had a diagnosis of chorea (involuntary muscle movements). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. She required extensive assistance of one staff for transfers, had impairment in range of motion (ROM) to her bilateral (both sides) lower extremities and used a wheelchair for mobility. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 02/15/23, documented 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 · D2023-08-17 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 43 residents with 15 residents sampled, including one resident reviewed for urinary catheter (a catheter (hollow tube) is inserted into the bladder to drain or collect urine). Based on observation, interview and record review, the facility failed to anchor the catheter tubing to one Resident's (R)8. Findings included: - The Physician Order Sheet (POS), dated 08/01/23, documented the resident had a diagnosis of urinary retention (inability to pass urine). The admission Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed moderate impairment. He required extensive assistance of one staff for toileting and did not have an indwelling urinary catheter (a catheter (hollow tube) is inserted into the bladder to drain or collect urine). The resident was frequently incontinent of urine. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 06/12/23, inaccurately documented the resident had an indwelling urinary catheter.…
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 · D2023-08-17 · 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 43 residents with 15 residents sampled including five residents reviewed for respiratory care. Based on observation, interview, and record review, the facility failed to timely change oxygen tubing for one Resident (R)33. Findings included: - Review of Resident (R)33's electronic medical record (EMR) revealed a diagnosis of chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. She used oxygen while a resident. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 06/17/23, documented the resident had a diagnosis of COPD and used supplemental oxygen. The Annual MDS, dated 04/15/23, documented the resident had a BIMS score of 13, indicating…
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 · D2023-08-17 · tag F0730 — isolatedObserve 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 43 residents. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for one of the five Certified Nurse Aides (CNA) reviewed, CNA N. Findings included: - Review of five employee personnel files, employed by the facility for greater than one year, revealed the following concern: Review of Certified Nurse Aide (CNA) N, hired 02/02/21, lacked an annual performance review in her personnel file. On 08/17/23 at 01:23 PM, Administrative Nurse D stated she had not completed an annual evaluation for this staff member who had been employed by the facility for greater than one year. The facility lacked a policy for the completion of staff's annual performance reviews. The facility failed to complete an annual performance review for this resident, employed by the facility for greater than one year.
- Potential for harm · F2021-12-02 · tag F0881 — failed to use antibiotics responsibly — widespreadImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 43 residents. Based on interview and record review, the facility failed to ensure principles of antibiotic stewardship would be followed by nursing staff to ensure antibiotics used in a safe and effective manner to prevent unnecessary side effects of antibiotics and antibiotic resistance in an ongoing, proactive manner. Findings included: - Review of the Infection Control Log for tracking and trending infections, revealed lack of diagnoses for antibiotics prescribed in January 2021 for four residents (R)3,11,21 and 96. Review of the October 2021 Infection Control Log revealed three residents (R38, R30 and R17) prescribed antibiotics without the Infection Control Worksheet completed in the electronic medical record. Interview, with Licensed Nurse (LN) G, revealed she acted as the facilities Infection Preventionist and completed the Infection Control Logs. Licensed Nurse G stated only the infections that met the McGreers Criteria were documented on the facility map for tracking and trending. The residents who were prescribed antibiotics 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 before2021-12-02 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 43 residents with 14 selected for review, which included six residents reviewed for accidents. The facility reported seven cognitively impaired mobile residents. Based on observation, interview and record review, the facility failed to ensure one Resident (R)12 transferred in a safe manner, and R15 shoelaces secured in a way to prevent entanglement in the wheelchair wheels. Furthermore, the facility failed to ensure the hydrocollator (a device that contains hot water that warms packs for application to areas to provide warm moist heat by therapy staff) used by therapy staff remained locked in the therapy room when staff were not in the area. In addition, the facility failed to secure chemicals in the beauty shop to prevent accidental contact with the seven cognitively impaired mobile residents in the facility and failed to ensure the kick plate on the exterior side of the patio door was securely attached to prevent accidental injury for the residents who used the patio. Findings…
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 · D2021-12-02 · 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 reported a census of 43 residents with 14 selected for review, with two residents reviewed for nutrition. Based on observation, interview and record review, the facility failed to review and revise the care plan for one Resident (R)12, that had an unplanned weight loss. Findings included: - Review of Resident (R)12's Physician Order Sheet, dated 11/01/21, revealed diagnosis included major depressive disorder(major mood disorder,) dementia (progressive mental disorder characterized by failing memory, confusion) with behavior disturbance, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and hypothyroidism (condition characterized by decreased activity of the thyroid gland.) The Quarterly Minimum Data Set (MDS), dated [DATE], assessed the resident with severely impaired cognitive function. The resident required extensive assistance of one person for eating. The resident had no impairment in range of motion in the upper or lower extremities. 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 before2021-12-02 · 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 43 residents with 14 residents included in the sample, including three residents reviewed for Activities of Daily Living (ADLs). Based on observation, interview, and record review, the facility failed to ensure the three sampled, dependent Residents (R)16, R 17 had appropriate bathing opportunities and R 18, regarding shaving of facial hair. Findings included: - The Physician Order Sheet (POS), dated 11/01/21, for Resident (R)16 included the following diagnosis: dementia (progressive mental disorder characterized by failing memory, confusion). The significant change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. He required limited assistance of one staff for personal hygiene. No bathing activity occurred during the assessment period. The Activity of Daily Living Functional/Rehabilitation Potential (ADL) Care Area Assessment (CAA), dated 05/25/21, documented 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 · D2021-12-02 · 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 reported a census of 43 residents with 14 selected for review, with two residents reviewed for nutrition. Based on observation, interview and record review, the facility failed to ensure one Resident (R)12, received appropriate nutritional opportunities and interventions to prevent unintentional weight loss. Findings included: - Review of Resident (R)12's Physician Order Sheet, dated 11/01/21, revealed diagnosis included major depressive disorder(major mood disorder,) dementia (progressive mental disorder characterized by failing memory, confusion) with behavior disturbance, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and hypothyroidism (condition characterized by decreased activity of the thyroid gland.) The Quarterly Minimum Data Set (MDS), dated [DATE], assessed the resident with severely impaired cognitive function. The resident required extensive assistance of one person for eating. The resident had no impairment in range of motion in…
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 · D2021-12-02 · 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 reported a census of 43 residents with 14 residents sampled, including six residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to monitor two Residents (R)16 and R 17, regarding psychotropic (medication capable of affecting the mind, emotions, and behavior) medications, to ensure no unnecessary antipsychotic medication usage. Findings included: - The Physician Order Sheet (POS), dated 11/01/21 for Resident (R) 16, documented a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The significant change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severely impaired cognition. The resident did not receive any psychotropic (medication capable of affecting the mind, emotions, and behavior) medications during the assessment period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 05/25/21, did…
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 · C2025-07-01 · 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 44 residents. Based on record review and interviews, the facility failed to submit accurate staffing information through Payroll Based Journaling (PBJ - Staffing Data Report), when the facility failed to submit accurate weekend staffing coverage hours.Findings included:- Review of the PBJ Quarterly Staffing Data Report documented that the facility had excessively low weekend staffing in Fiscal Year (FY) 2024 Quarter (Q) 3, FY 2024 Q4, FY 2025 Q1, and FY 2025 Q2.Review of the Nursing Schedule and nursing hours for weekend staffing during the above-noted quarters revealed staffing was adequate and consistent with the weekday (Monday through Friday) staffing patterns.On 07/01/25 at 12:38 PM, Administrative Staff A and Administrative Nurse D reviewed the PBJ reports, the nursing schedule, and daily staff postings for the weekends of the above-noted quarters and concurred that the PBJ Data Reports were inaccurate. They stated the facility's administrative nurses often filled in on the weekends to provide direct care. They confirmed those hours 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.
- No harm found · C2021-12-02 · 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 43 residents. Based on observation, record review and interview, the facility failed to display accurate, publicly accessible, and identifiable staffing information, on a daily basis, for the 43 residents who reside in the facility. Findings included: - Review of the facility's Daily Staffing Sheets, for the past 90 days, revealed the actual hours worked had not been completed on the daily staffing sheets. On 12/02/21 at 09:51 AM, Administrative Nurse D stated, the actual hours worked had not been filled in on the daily staffing sheets, as they should have been. The facility policy for Nurse Staffing Posting Information, undated, included: The nurse staffing information will be posted on a daily basis and will contain the actual hours worked. The facility failed to properly complete the daily staffing sheets for the residents of the facility.
“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
$22,048 in federal fines across 1 penalty.
- $22,048 — penalty dated 2025-07-01
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 | 4 of 5 | 2.4 | +1.6 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 | 5 of 5 | 3.1 | +1.9 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 11/01/2019 |
| 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 |
| 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; OPERATIONAL/MANAGERIAL CONTROL | since 02/28/2025 |
| MRC SNF MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/12/2025 |
| PENNINGTON, SUSAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/12/2025 |
| PETERSEN, MARK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/28/2025 |
| THOMAS, ANGIE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 02/28/2025 |
CMS files one row per role, so the 32 rows in the source record cover these 21 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 $691K paid to related parties — landlords or management companies under common ownership — equal to about 19% 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 175280. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-01, 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.