Parkview Heights Nursing And Rehabilitation Center
101 N Pine Street, Garnett, KS 66032 · For profit - Corporation · 45 certified beds · (785) 448-2434 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 | 16.2% | 17.9% | 15.4% | typical |
| Long-stay residents who lose too much weight | 1.8% | 4.9% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 3.6% | 1.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.0% | 2.9% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 1.5% | 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 | 1.9% | 4.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 18.5% | 16.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 13.1% | 23.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 97.2% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.8% | 4.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 26.9% | 22.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 13.6% | 18.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 9.4% | 1.9% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 41.4% | 73.8% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 24.9% | 22.4% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 22.8% | 11.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.09 | 1.80 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.33 | 2.13 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
49.3% 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 29 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 65.0% 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 0.37 therapist hours per resident per day in 2026Q1 — more than 64% 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 | 49.3%CMS range 35.8–64.4 | 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 | 10.7%CMS range 6.9–16.8 | 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 | 65.0% | 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 | 55.0% | 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 | 47.5% | 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 | 98.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.0% | 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 | 6.1% | 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 | 6.9%CMS range 3.1–13.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.17 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 45 beds and averages 42.3 residents a day — about 94% occupied, or roughly 3 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 3.77 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.68 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 3.46 hrs/resident/day on weekends vs 3.89 on weekdays — 11% thinner on weekends. RN hours go from 0.48 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 39% 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.
24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.
- Potential for harm · Ecited before2026-05-21 · tag F0641 — patternEnsure 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 Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for four residents: Resident (R) 3, R2, R14 and R30, related to anticoagulant medication (medication used to prevent clotting).Findings included:1. R3's Electronic Medical Record (EMR) recorded a Minimum Data Set (MDS), dated [DATE], which documented R3 received an anticoagulant medication (medication used to prevent clotting) during the assessment look-back period.R3's EMR under the Orders tab, revealed the following Physician's Order:Plavix (an antiplatelet medication), 75 milligrams, by mouth, every day, for a diagnosis of atherosclerosis arteries of extremities (when fatty plaque builds up in the arteries that supply blood to your limbs), ordered 01/19/19.2. R14's Electronic Medical Record (EMR) recorded a Minimum Data Set (MDS), dated [DATE], which recorded R14 received an anticoagulant medication (medication used to prevent clotting) during the assessment look-back period.R14's EMR…
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 · D2026-05-21 · 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 Based on observation, record review, and interview, the facility failed to ensure Resident (R) 7 received assistance with activities of daily living (ADL) of cleansing off her face. Findings included:- R7's Electronic Medical Record (EMR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) and weakness.R7's Significant Change Minimum Data Set (MDS), dated [DATE], documented R7 had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. R7 MDS revealed she had no behaviors and R7 required moderate assistance with personal hygiene. R7's Falls Care Area Assessment (CAA), dated 03/25/25, documented R7 required assistance with mobility and hygiene. R7's Care Plan, dated 10/11/23, instructed staff that R7 was dependent on staff for personal hygiene. R7's Physician Orders, documented Valtrex (is a prescription antiviral medication used to treat and manage viral infections like cold sores), give 1 gram, 1 tablet, by mouth…
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 before2026-05-21 · 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 Based on observation, interview, and record review, the facility failed to identify and implement resident-centered fall interventions for Resident (R) 7, R2, and R13 who were at risk for falls.Findings included:- R7's Electronic Medical Record (EMR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) and unsteadiness on feet. R7's Significant Change Minimum Data Set (MDS), dated [DATE], documented R7 had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. R7 required supervision and touching for transfers, standing, and walking 150 feet; no falls documented. R7's Falls Care Area Assessment (CAA), dated 03/25/25, documented R7 had experienced falls during the lookback window; fall on 03/14/26 resulted in an intra-thalamic bleed (thalamic hemorrhage is a type of stroke that occurs when a blood vessel ruptures within the thalamus) and three right side rib fractures (broken bone). R7 required assistance with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-21 · 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 Based on observation, interview, and record review, the facility failed to ensure Resident (R)2 received the necessary nutritional support when staff failed to provide a breakfast meal for several days in May 2026. Findings include:- R2's Electronic Medical Record (EMR) revealed diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by decreased blood flow to the brain) and dysphagia (swallowing difficulty). R2's admission Change Minimum Data Set, (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of seven, indicating severely impaired cognition. R2's MDS revealed he required touching assistance for eating; he had no weight loss and was on a therapeutic diet.R2's Nutritional Status Care Area Assessment (CAA), dated 01/15/26, documented R2 was participating in speech therapy services at a skilled level of care due to dysphagia. R2 received a regular diet of mech soft texture and thin consistency. R2 typically eats 76-100% 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 · D2026-05-21 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record and interview, the facility failed to ensure all residents were free from significant medication errors when a staff member administered 30 units of insulin to Resident (R)13, who was not a diabetic.Findings included: - R13's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion).R13's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. She did not have a diagnosis of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) and did not receive insulin during the seven-day lookback period.R13's Cognitive Loss/Dementia Care Area Assessment, dated 11/27/25, documented R13 had severe cognitive limitations.R13's Quarterly MDS, dated [DATE], documented she had a BIMS score of three, indicating severe cognitive impairment. She did not receive…
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 · D2026-05-21 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff provided cognitively impaired Resident (R) 7 with her prescribed nectar thickened (liquid with slightly higher viscosity that pour easily but leave a coating on the glass or spoon, they slow down the swallowing process to prevent fluids from entering the lungs) liquids. Findings included:- R7's Electronic Medical Record (EMR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) and weakness.R7's Significant Change Minimum Data Set (MDS), dated [DATE], documented R7 had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. R7's MDS revealed she was independent with eating. R7's Nutritional Status Care Area Assessment, dated 03/25/25, documented R7 had a prescribed regular diet of regular texture and thin liquids. Consumes 76-100% of meals and snacks of most meals but eating has become more sporadic. Resident has selected hospice…
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 · D2026-05-21 · 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
Based on interviews, observation, 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 direct care to a Resident (R) 7 with open wounds to her knees. Additionally, the facility failed to ensure adequate hand hygiene during a dressing change for R7 and perineal care for R2. The facility failed to properly transport clean personal linens.Findings included:1. On 05/19/26 at 03:32 PM Certified Nurse Aide (CNA) L and CNA N applied gloves, neither CNA performed hand hygiene, nor did they apply any other personal protective equipment (PPE- gowns, face shields and/or eyeglasses/goggles, and gloves) before they assisted R7 to the bathroom and transferred her to the toilet. R7 had a dressing on each of her knees. CNA N removed R7's soiled brief. CNA L then removed her gloves without performing hand hygiene and tried to find R7 a different pair of shoes to wear in her closet. CNA L then applied…
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 · D2026-05-21 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to offer and provide or obtain an informed declination for the COVID-19 vaccine (a vaccine designed to prevent highly contagious respiratory virus) for Resident (R) 2. Additionally, the facility failed to maintain staff documentation of screening, education, offering, and current COVID-19 vaccination status. Findings included:1. R2's Electronic Medical Record (EMR) lacked documentation of a COVID-19 vaccine being offered since 2022.On 05/21/26 at 12:50 PM, Administrative Nurse D (Infection Preventiveness) reported that the facility does not maintain staff documentation of screening, education, offering, and current COVID-19 vaccination status, and that if a staff member was ill then they are told to go to their provider and to let the facility know. The facility's policy Infection Prevention and Control Program, dated 02/15/26, documented COVID-19 Immunization:Residents and staff will be offered the COVID-19 vaccines when vaccine supplies are available to the facility. If COVID-19 vaccination requires multiple doses, 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 · F2024-08-14 · 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 35 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 staffing information, when the facility failed to accurately report 24 hour per day Licensed Nurse coverage on eight dates between 04/01/23 and 06/30/23 and five dates between 10/01/23 and 12/31/23. Findings Included: - Review of the Payroll Base Journal (PBJ) Staffing Data Report for fiscal year (FY),Quarter 3 2023 (April 1- June 2023) revealed lack of License Nurse (LN) for 24 hours/seven days a week 24 hour/day on the following dates: On 05/06, Saturday (SA), On 05/07, Sunday (SU), On 05/21, SU, On 06/10, SA, On 06/11. SU, On 06/24, SA, On 06/25, SU, Review of the PBJ for FY, Quarter 1, 2024 (October 1-December 1), revealed the following infraction dates 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 · E2024-08-14 · tag F0636 — patternAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 35 residents with 14 residents selected for review. Based on observation, interview and record review, the facility failed to complete and analysis of findings for the Minimum Data Set (MDS), triggered Care Area Assessments (CAA) to complete a comprehensive assessment and develop a care plan for four of the 14 residents selected for review. This included Resident(R) 15, for Delirium; Cognitive Loss/Dementia, Psychotropic Drug Use and Pain, R 14 for Delirium, Cognitive Loss/Dementia, Psychotropic Drug Use, Psychosocial Well-Being, Pain, Mood State, Falls, Urinary Incontinence and Indwelling Catheter, R31 for Cognitive Loss/Dementia, Mood State, Psychotropic Drug Use, and Behavioral Symptoms and R8 for Urinary Incontinence and Indwelling Catheter, ADL (Activity of Daily Living) Functional/Rehabilitation Potential, Pain, and Return to Community to develop 'Comprehensive Care Plans as required. This deficient practice had the potential to lead to uncommunicated care needs. 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.
Show the remaining 14 citations
- Potential for harm · Dcited before2024-08-14 · 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
The facility reported a census of 35 residents with 14 residents sampled, including two residents reviewed for respiratory services. Based on observation, record review, and interview, the facility failed to complete a comprehensive care plan for one Resident (R)33, regarding the use of a Continuous Positive Airway Pressure (CPAP-a non-invasive positive airway pressure) for one Resident (R)33. Findings included: - Review of Resident (R) 33's electronic medical record (EMR) revealed a diagnosis of sleep apnea (a sleep disorder characterized by periods without respirations). The Modification of admission Minimum Data Set (MDS), dated 07/08/24, documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident did not utilize a Continuous Positive Airway Pressure (CPAP-a non-invasive positive airway pressure). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/08/24, did not trigger. The care plan, revised 07/12/24, lacked staff instruction on the use and care of the resident's CPAP. Review of the resident's EMR…
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 before2024-08-14 · 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 35 residents with 14 residents sampled, including two residents reviewed for positioning. Based on interview, record review, and observation, the facility failed to ensure appropriate positioning for one Resident (R)4, while in her specialized wheelchair. Findings included: - Review of Resident (R)4's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the staff assessment to reveal severe cognitive impairment. The resident was dependent on staff for mobility in a wheelchair. The Functional Abilities Care Area Assessment (CAA), dated 02/29/24, did not trigger. The Cognitive Loss/Dementia CAA, dated 02/29/24, triggered but lacked an analysis of findings. The Quarterly MDS, dated 05/23/24, documented the resident's Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. The 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 · Dcited before2024-08-14 · 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 35 residents with 12 residents sampled, including five residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide safe transfers for two Residents (R)4 and R 15, and failed to provide safe wheelchair transport for one R 28. Findings included: - Review of Resident (R)15's electronic medical record (EMR), revealed 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 five, indicating severe cognitive impairment. She required supervision to touching assistance with chair to bed to chair transfers and had no limitation in functional range of motion (ROM). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 01/04/24, triggered but lacked an analysis of findings. The Functional Abilities CAA, dated 01/04/24, did not trigger. 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 before2024-08-14 · 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
The facility reported a census of 35 residents with 14 residents sampled, including two residents reviewed for respiratory services. Based on observation, record review, and interview, the facility failed to obtain a physician's order for the use of a Continuous Positive Airway Pressure (CPAP-a non-invasive positive airway pressure) for one Resident (R)33. Findings included: - Review of Resident (R) 33's electronic medical record (EMR) revealed a diagnosis of sleep apnea (a sleep disorder characterized by periods without respirations). The Modification of admission Minimum Data Set (MDS), dated 07/08/24, documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident did not utilize a Continuous Positive Airway Pressure (CPAP-a non-invasive positive airway pressure). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/08/24, did not trigger. The care plan, revised 07/12/24, lacked staff instruction on the use and care of the resident's CPAP. Review of the resident's EMR lacked a physician's order and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-12-08 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
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 33 residents. Based on record review, and interviews, the facility failed to provide a certified infection preventionist to oversee the facility's Infection Prevention and Control Program (IPCP). This deficient practice placed all residents at increased risk of infections related tor lack of identification, tracking/trending, and treatment of infections. Findings included: - On 12/08/22 at 01:56 PM Administrative Nurse E reported that she assumed the responsibilities of infection preventionist after the previous nurse quit the facility last August. She stated that she was currently working on becoming certified and only had four learning modules left. On 12/08/22 at 0245 PM Administrative Nurse D reported that the facility's previous certified infection preventionist left the faciity on [DATE]. The she stated that Administrative Nurse E had assumed the IPCP duties and began taking classes to become certified in August of 2022. The facility was unable to provide a policy…
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 · D2022-12-08 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 33 residents with 13 selected for review. Based on observation, interview, and record review, the facility failed to conduct an assessment for Resident (R)15 to determine the safety for self-administration of vaporizing rub ointment. This placed R15 at risk to use the vaporizing rub ointment in an unsafe manner. Findings included: - The Medical Diagnosis tab for R15 included diagnoses of chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), chronic respiratory failure with hypoxia (inadequate supply of oxygen), and pulmonary hypertension (high blood pressure affecting arteries in the lungs and right side of the heart that can cause shortness of breath, chest pressure, and dizziness). The Quarterly Minimum Data Set (MDS) dated [DATE] assessed R15 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition and required oxygen. The Annual…
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 before2022-12-08 · 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 33 residents with 13 selected for review. One resident was reviewed for elopement (when a cognitively impaired resident leaves the facility without staff knowledge and /or supervision). Based on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS) for one of the residents, Resident (R)4, for wander/elopement alarm (device worn on the resident or attached to assistive device such as walker or wheelchair or other personal belongings, to alert the staff when a resident nears or exits a specific area of the building). This placed the resident at risk for uncommunicated care needs. Findings included: - The admission Minimum Data Set (MDS) dated [DATE] for R4 revealed she wandered one to three days of the assessment period and did not require the use of a wander/elopement alarm. The facility Elopement Risk binder included a Missing Resident Identification form, dated 11/04/22 for R4. On 12/06/22 at 07:10 AM observed a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-12-08 · 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 33 residents with 13 selected for review. Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan to direct staff care for one of the resident's, Resident (R)4, to address her risk of elopement (when a cognitively impaired resident leaves the facility without staff knowledge and/or supervision). This placed the resident at risk for uncommunicated care needs. Findings included: - The Medical Diagnoses tab for R4 included a medical diagnosis of disorientation (confusion about the time, your location, or even who you are). The admission Minimum Data Set (MDS) dated [DATE] assessed R4 with a Brief Interview of Mental Status score of six, indicating severe cognitive impairment. R4 had disorganized thinking and inattention, she wandered one to three days of the assessment period. She required supervision and setup for walking and required the use of a walker for mobility. The Cognitive Loss/Dementia Care Area Assessment (CAA) 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 · D2022-12-08 · 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
The facility identified a census of 33 residents. The sample included 13 residents with two reviewed for care plan revisions. Based of observations, record review, and interviews, the facility failed to implement updated fall interventions after Resident (R) 7 fell while using the restroom. This deficient practice placed R7 at risk for preventable falls and injuries due to uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R7's Electronic Medical Records (EMR) included diagnoses of cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth),blindness in one eye, dysphagia (swallowing difficulty), epilepsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth), and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). R7's Quarterly Minimum Data Set (MDS) dated 10/21/22 noted a Brief Interview for Mental…
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 before2022-12-08 · 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
The facility identified a census of 33 residents. The sample included 13 residents with 13 reviewed for quality of care. Based on observations, record review, and interviews, the facility failed to follow physician ordered instructions to weigh Resident (R)3 daily. The facility additionally failed to report weight changes to the medical provider as instructed in the order parameters. This deficient practice placed R3 at risk for complications related to edema (swelling resulting from an excessive accumulation of fluid in the body tissues). Findings Included: - The Medical Diagnosis section within R3's Electronic Medical Records (EMR) included diagnoses of type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), bradycardia (low heart rate, less than 60 beats per minute), localized edema, chronic kidney disease, congestive heart failure (CHF- when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and hypertension (high blood pressure). R3's Quarterly Minimum Data…
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 before2022-12-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 33 residents. The sample included 13 residents with three reviewed for accidents. Based on observations, record review, and interviews, the facility failed to identify and/or address causative factors for Resident (R)27 resulting in repeated falls. The facility additionally failed to identify R15's potentially flammable use of petroleum-based vapor rub medication with supplemental oxygen and failed to monitor R4's Wanderguard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort). This deficient practice placed the residents at risk for preventable injuries and accidents. Findings Included: - The Medical Diagnosis section within R27's Electronic Medical Records (EMR) included diagnoses of cellulitis anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), type two diabetes…
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 · D2022-12-08 · 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
The facility identified a census of 33 residents. The sample included 13 residents with three reviewed for bowel and bladder management. Based of observations, record review, and interviews, the facility failed to provide individualized toileting interventions for Resident (R)27. This deficient practice placed R27 at risk for urinary tract infections and preventable falls. Findings Included: - The Medical Diagnosis section within R27's Electronic Medical Records (EMR) included diagnoses of cellulitis anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), major depressive disorder (major mood disorder), difficulty walking, abnormalities of gait and mobility, and spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities). R27's Quarterly Minimum Data Set…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-08 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 33 residents with 13 selected for review including one resident reviewed, Resident (R)29, for presence of a percutaneous endoscopic gastrostomy (PEG - tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) tube. Based on observation, interview, and record review, the facility failed to flush the PEG tube daily, which was not being utilized to administer food, fluids, or medications, to ensure patency of the tube. This placed the resident at risk for complications related to her PEG tube. Findings included: - The Medical Diagnosis tab for R29 included diagnoses of gastrostomy status, protein-calorie malnutrition, and adult failure to thrive. The admission Minimum Data Set (MDS) dated [DATE] revealed R29 admitted to the facility on [DATE] and assessed her with a Brief Interview of Mental Status score of 15, indicating intact cognition. R29 had a feeding tube while and while not a resident and received…
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 before2022-12-08 · 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 33 residents with 13 selected for review including three residents reviewed for respiratory care. Based on observation, interview, and record review, the facility failed to change the oxygen nasal cannula and the nebulizer (device which changes liquid medication into a mist easily inhaled into the lungs) kit tubing for Resident (R)15. These practices increased the risk of R15 for developing a respiratory infection. Findings included: - The Medical Diagnosis tab for R15 included diagnoses of chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), chronic respiratory failure with hypoxia (inadequate supply of oxygen), and pulmonary hypertension (high blood pressure affecting arteries in the lungs and right side of the heart that can cause shortness of breath, chest pressure, and dizziness). The Quarterly Minimum Data Set (MDS) dated [DATE] assessed R15 with a 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.
“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 | 4 of 5 | 2.4 | +1.6 vs chain |
| Health inspection | 4 of 5 | 2.5 | +1.5 vs chain |
| Staffing | 4 of 5 | 2.4 | +1.6 vs chain |
| Quality measures | 2 of 5 | 3.1 | -1.1 vs chain |
The other 26 homes this chain runs (chain average 2.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| MRCMM III LLC | Organization | DIRECT OWNERSHIP INTEREST | since 02/28/2025 |
| RECOVER-CARE HEARTLAND LLC | Organization | DIRECT OWNERSHIP INTEREST | since 02/28/2025 |
| BHNV 2 LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 02/28/2025 |
| KANSAS HEALTHCARE 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 |
| 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 SNF HOLDINGS 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 07/01/2025 |
| 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 05/29/2025 |
| CUBIT, SUZANNA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 02/28/2025 |
| KARNES, CASEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/12/2025 |
| PETERSON, MACKENZIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/28/2025 |
CMS files one row per role, so the 29 rows in the source record cover these 18 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.
12 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 $304K 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 175433. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-21, 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 →
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