Providence Place
8909 Parallel Pky, Kansas City, KS 66112 · For profit - Corporation · 45 certified beds · (913) 596-4200 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
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) | 4 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
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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 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 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 | 17.7% | 17.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 12.1% | 4.9% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.7% | 1.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.9% | 2.9% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 23.5% | 6.5% | 6.5% | worse |
| 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 | 0.9% | 4.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 8.4% | 16.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 9.4% | 23.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 93.5% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.8% | 4.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 25.8% | 22.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 3.6% | 18.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 1.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 85.3% | 73.8% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 32.7% | 22.4% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 10.5% | 11.5% | 12.0% | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
68.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 123 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 87.8% 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 82 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 0.73 therapist hours per resident per day in 2026Q1 — more than 93% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 68.3%CMS range 59.0–76.7 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.5%CMS range 8.3–15.6 | 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 | 87.8% | 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 | 82.9% | 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 | 69.5% | 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 | 95.3% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 98.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 2.4% | 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 3.9–10.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.82 | 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 43.4 residents a day — about 96% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. 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 3.80 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.04 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.80 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.21 hrs/resident/day on weekends vs 4.03 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 1.09 to 0.91 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% 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 unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.
- Potential for harm · F2025-08-12 · 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 identified a census of 35 residents. The facility had one main kitchen and one dining area. The facility failed to ensure that staff members properly tested the dishwashing sanitization chemicals. The facility also failed to ensure food items were labeled and dated when opened. These deficient practices placed residents at risk for contamination and foodborne illness.Findings included:- During the initial tour of the kitchen and dining room area on 08/10/25 at 10:05 AM, an open undated gallon of milk was in the refrigerator. During review of the dishwashing process, Dietary Staff BB stated the facility had not started using the dishwashing machine and washed the dishes by hand in the three-sink system. Dietary Staff BB stated that the facility washed the dishes in hot water and chemicals. Dietary Staff stated the facility did not have test strips at that time to test the water or have a log to review.On 08/12/25 at 10:11 AM, Dietary Staff BB stated that every item that was opened should be labeled and dated. Dietary Staff BB stated the facility had received 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 · Ecited before2025-08-12 · 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 identified a census of 64 residents. The sample included 16, with three reviewed for accidents. Based on observation, record review, and interview, the facility failed to secure potentially hazardous cleaning chemicals in a safe, locked area and out of reach of eight cognitively impaired, independently mobile residents. The facility additionally failed to safely transfer Resident (R) 37, resulting in a non-injury fall, and ensure R9's fall interventions were followed. This placed the affected residents at risk for preventable accidents.Findings Included:- On 08/10/25 at 10:10 AM, an initial walkthrough of the facility was completed. An inspection of the 300 Hall revealed an unsecured cabinet across from the vending machine that contained disinfectant bleach wipes and a Clorox spray bottle. Both containers contained the warning, Keep out of reach of children, hazardous to humans, can cause eye irritation, harmful if swallowed. On 08/12/25 at 10:00 AM, a Certified Nurse’s Aide (CNA) M stated that…
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 before2025-08-12 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 44 residents. The facility identified two medication rooms and four medication carts. Based on observations, record reviews, and interviews, the facility failed to secure one of two medication storage rooms. This deficient practice placed the residents at risk for unnecessary medication and administration errors.Findings Included:- On 08/10/25 at 10:05 AM, an initial walkthrough of the facility was completed. An inspection of the 100 Hall Team Office medication storage room revealed that the door was not secured. An inspection of the medication storage room revealed shelves of stock medication, enteral feeding solutions, and medical supplies. On 08/10/25 at 10:11 AM, Licensed Nurse (LN) G stated the door should be locked at all times due to the medications in the room. She stated that sometimes the doorknob would stick and not close properly. She stated staff were expected to ensure the room remained locked when exiting. LN G secured the room at 10:14 AM. On 08/12/25 at 10:30 AM, Administrative Nurse D stated staff were expected to ensure 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 · Ecited before2025-08-12 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 35 residents. The facility identified seven residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record reviews, observations, and interviews, the facility failed to ensure trash was stored and contained properly. The facility further failed to ensure trash was not left on top of the Personal Protective Equipment (PPE) cart, and the clean linen door was not propped open. The facility further failed to ensure soap and paper towels were available in the same room, and gloves were available in the dirty laundry area, and all staff knew where the hand washing sink was in the laundry room. These deficient practices placed the residents at risk for infectious diseases.Findings included:- An initial walkthrough of the facility was completed on 08/10/25 at 07:05 AM. A clear bag of trash was left on top of a PPE cart in the 300…
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 · D2025-08-12 · 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
The facility reported a census of 44 residents. The sample included 12 residents, with one reviewed for activities of daily living (ADL). Based on record review, interviews, and observations, the facility failed to ensure Resident (R) 17 received supportive care and services to promote and maintain his quality of life when the facility failed to provide him with his required adaptive utensils while eating his meals. This deficient practice placed the resident at risk for decreased quality of life, isolation, and impaired dignity. Findings Included:- R17's Medical Diagnosis section within the Electronic Medical Record (EMR) noted diagnoses of left sided hemiplegia (paralysis of one side of the body), 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), dysphagia (difficulty swallowing), muscle weakness, cognitive communication disorder (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), reduced mobility,…
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 before2025-08-12 · 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 identified a census of 35 residents. The sample included 12 residents, with three residents reviewed for activities of daily living (ADL) care. Based on observation, record review, and interviews, the facility failed to ensure staff assisted Resident (R) 23 with ensuring his fingernails were kept clean. This deficient practice placed R23 at risk for impaired dignity, comfort, and further decline in ADL. Findings Included: - R23's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), hemiparesis (muscular weakness of one half of the body) following a cerebrovascular accident (CVA- stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting the right dominant side, muscle weakness, need for assistance with personal care, hypertension (high blood pressure), Parkinson's disease (a slowly…
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 before2025-08-12 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 35 residents. The sample included 12 residents, with two residents reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to consistently communicate Resident (R) 51 medical condition with a pre- and post-dialysis communication prior to and post-hemodialysis. This deficient practice placed R51 at risk of potential adverse outcomes and physical complications related to dialysis. Findings included:- R51's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of end-stage renal disease (ESRD- a terminal disease of the kidneys) with dialysis (procedure where impurities or wastes were removed from the blood), hypertension (high blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major depressive disorder (major mood disorder that causes persistent feelings 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 · D2025-08-12 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 35 residents. The sample included 12 residents, with four residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure that Resident (R) 4 had a documented risk assessment that included alternatives that had been tried and failed. This placed the R4 at risk for uninformed decisions and impaired safety related to the risks associated with the use of siderails.Findings included:- R4's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and cerebrovascular accident (CVA- stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The admission Minimum Data Set (MDS) dated 05/08/25 documented a Brief Interview of Mental Status (BIMS) score of four, which indicated severely impaired…
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 · D2025-08-12 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 35 residents. The sample included 12 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to act upon the Consultant Pharmacist (CP) recommendations for Resident (R) 4. This deficient practice placed R4 at risk for unnecessary medication use, side effects, and physical complications.Findings included:- R4's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and cerebrovascular accident (CVA- stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The admission Minimum Data Set (MDS) dated 05/08/25 documented a Brief Interview of Mental Status (BIMS) score of four, which indicated severely impaired cognition. The MDS documented R4 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 · Fcited before2023-11-01 · 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 had a census of 29 residents. Based on observation, interview, and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal year (FY) 2023 Quarter 2 and Quarter 3 indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on multiple (10) dates. Review of the facility licensed nurse timeclock data for the dates listed on the PBJ revealed a licensed nurse was on duty for 24 hours a day seven days a week. On 11/01/23 at 02:24 PM, an observation revealed a licensed nurse on duty in the facility. On 11/01/23 at 12:05 PM Administrative Staff A stated staff reporting to CMS was done through the hospital/previous owners and would be until the end of November 2023. He stated the facility would take over staff reporting in December 2023.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 19 citations
- Potential for harm · E2023-11-01 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 29 residents. The sample included 13 residents. Based on record review, interviews, and observations, the facility failed to provide wheelchair foot pedals for Residents (R)15, R178, R21, and R175. This deficient practice placed the residents at risk for impaired safety and comfort. Findings Included: - On 10/30/23 at 07:34AM staff transported R15 from the main hallway to the dining room in a wheelchair. R15's wheelchair lacked foot pedals. R15 wore socks and his feet slid on the floor as he was pushed to the dining room. A review of R15's Care Plan revealed no documented interventions related to his foot pedals. On 10/30/23 at 11:33PM housekeeping staff pushed R178 down the main hallway in his wheelchair. R178's wheelchair did not have foot pedals in place and his feet made contact with the ground on several occasions. A review of R178's Care Plan revealed no documented interventions related to his foot pedals. On 11/01/23 at 01:16PM staff transported R21 from the dining room to his room in a wheelchair without foot pedals. R21 had non-slip socks…
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 before2023-11-01 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 29 residents. Based of observations, record review, and interviews, the facility failed to ensure safe storage of medications for one of three medication rooms. This deficient practice placed the residents at risk for unnecessary medication and administration errors and/or diversion. Findings Included: - On 10/20/23 at 07:05AM a walkthrough of the facility's Prairie View hallway revealed the medication storage room door was propped fully open and unattended by nursing staff. The medication storage cart within the room was left unlocked and contained medications for all five residents on the Prairie View hallway, Resident (R)8, R11, R13, R19 and R125. At 07:21AM Licensed Nurse (LN) G entered the hallway and reported the medication room should not have been left open. She stated she was not sure why the room was propped open, or the cart left unlocked. She stated staff were to ensure they secured the door as the left the room. On 11/02/23 at 02:05PM Administrative Nurse D stated staff were expected to securely close the medication room doors when 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 · D2023-11-01 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 29 residents. The sample included 13 residents with one reviewed for notification of changes. Based on observation, record review, and interviews, the facility failed to notify Resident (R)127's medical provider of her weight loss or changes in meal intake. This deficient practice placed R127 at risk for complication related to weight loss and malnutrition (condition that develops when the body is deprived of vitamins, minerals and other nutrients) due to delayed physician involvement. Findings Included: - The Medical Diagnosis section within R127s Electronic Medical Records (EMR) included diagnoses of chronic kidney disease, osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), muscle weakness, history of fractures (broken bones), and history of falls. R127's admission Minimum Data Set (MDS) dated 10/11/23 noted a Brief Interview for Metal Status (BIMS) score of nine indicating moderate cognitive impairment. The MDS indicated she required set-up assistance with meals. The MDS indicated she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-01 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 29 residents. The sample included 13 residents. Based on observation, record review, and interviews, the facility failed to secure protected health information (PHI) for Resident (R)125. This deficient practice placed R125 at risk for decreased psychosocial wellbeing due to lack of privacy. Findings Included: - The Medical Diagnosis section within R125's Electronic Medical Records (EMR) included diagnoses of fracture of right femur (broken bone), aphasia (difficulty speaking), dementia (progressive mental disorder characterized by failing memory, confusion), and a cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). R125's admission Minimum Data Set (MDS) dated 10/11/23 noted a Brief Interview for Metal Status (BIMS) score of three indicating severe cognitive impairment. The MDS indicated he was independent with ambulation and utilized a manual wheelchair and dependent for staff assistance for mobility over 50 feet. R125's Communication…
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 before2023-11-01 · 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 identified a census of 29 residents. The sample included 13 residents. Based on observations, record review, and interviews, the facility failed to provide the necessary care and services for activities of daily living (ADL) for Resident (R)5 when staff pulled on R5 under her arms instead of using available equipment to assist in repositioning her. This deficient practice placed R5 at risk for injury. Findings included: - R5's Electronic Medical Record (EMR) documented diagnoses age related osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), unsteadiness on feet, and 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 left side. The Annual Minimum Data Set (MDS) dated 04/25/23, documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-01 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 29 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 1 had the physician-ordered ankle foot orthotics (AFO-brace that supports the ankle and foot)and services to prevent reduction of range of motion [ROM] and/or mobility. This deficient practice left R1 at risk for further decline and decreased ROM or mobility. Findings included: - R1's Electronic Medical Record (EMR) documented a diagnosis of generalized muscle weakness, contracture (abnormal permanent fixation of a joint or muscle) of the left and right elbow, wrist, and shoulders, 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 left side. The Annual Minimum Data Set (MDS) dated 09/02/23, documented a Brief Interview for Mental Status (BIMS) score of 15 which…
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 · D2023-11-01 · 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 29 residents. The sample included 13 residents with three reviewed for bowel and bladder management. Based on observation, record review, and interviews, the facility failed to implement individualized interventions to improve/maintain Resident (R)15's bowel and bladder incontinence. This deficient practice placed R15 at risk for complications related to incontinence. Findings Included: - The Medical Diagnosis section within R15s Electronic Medical Records (EMR) included diagnoses of chronic kidney disease, acute kidney failure, history of falls, weakness, and a need for assistance with personal care. R15's admission Minimum Data Set (MDS) dated 10/14/23 noted a Brief Interview for Mental Status (BIMS) score of 11 indicating mild cognitive impairment. The MDS indicated he required partial to moderate assistance with toileting care and transferring. The MDS noted he was frequently incontinent of bowel and bladder with no toileting program. R15's Urinary Incontinence Care area Assessment (CAA) completed 10/21/23 indicated he had an alteration 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 · D2023-11-01 · 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
The facility identified a census of 29 residents. The sample included 13 residents with one reviewed for nutrition. Based on observation, record review, and interviews, the facility failed to monitor Resident (R)127's weight loss or changes in dietary intake. This deficient practice placed R127 at risk for complication related to weight loss and malnutrition (condition that develops when the body is deprived of vitamins, minerals and other nutrients). Findings Included: - The Medical Diagnosis section within R127s Electronic Medical Records (EMR) included diagnoses of chronic kidney disease, osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), muscle weakness, history of fractures (broken bones), and history of falls. R127's admission Minimum Data Set (MDS) dated 10/11/23 noted a Brief Interview for Metal Status (BIMS) score of nine indicating moderate cognitive impairment. The MDS indicated she required set-up assistance with meals. The MDS indicated she weighed 117.2 pounds (lbs.). The MDS documented the resident was not on…
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 · D2023-11-01 · 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 identified a census of 29 residents. The sample included 13 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to provide adequate pulse monitoring for Resident (R)125's anti-hypertensive beta-blocker (class of medication used to treat high blood pressure). This deficient practice placed R125 at risk for unnecessary medications and adverse medication effects. Findings Included: - The Medical Diagnosis section within R125's Electronic Medical Records (EMR) included diagnoses of fracture of right femur (broken bone), aphasia (difficulty speaking), dementia (progressive mental disorder characterized by failing memory, confusion), cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and congestive heart failure (a condition with low heart output and the body becomes congested with fluid). R125's admission…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-03-30 · 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 identified a census of 34 residents. Based on observations, record reviews, and interviews, the facility failed to ensure appropriate hand hygiene during dining service; the facility failed store respiratory equipment in a sanitary manner; and the facility failed to maintain sanitary handling of clean linen. This placed the affected residents at increased risk for infections. Findings Include: - On 03/28/22 at 09:18 AM an observation of R20's room revealed his oxygen tubing and nasal cannula (breathing device that delivers concentrated oxygen into both nostrils) lying on top of his soiled bed pad on his bed. An inspection of R20's oxygen concentrator (machine that delivers measurable prescribed oxygen to residents) revealed that the concentrator had no bag for storing the cannula or date indicating how long the tubing has been in use. R20's dirty bed linen blanket, heel floats, and soiled pillow were placed directly on top of his recliner in his room. An observation of R20's floor revealed two bloody cotton balls and a used diabetic (when the body cannot use glucose,…
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 · D2022-03-30 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 34 residents. The sample included 13 residents, with four residents reviewed for dignity. Based on observation, record review, and interviews, the facility failed to acknowledge and honor Resident (R) 18's right for self-determination to sleep undisturbed without feeling interference, or reprisal from the facility staff. The facility further failed to ensure R24's and R25's right to be treated with respect, dignity, and care during meals. These deficient practices placed the residents at risk for negative psychosocial outcomes and decreased autonomy and dignity. Findings included: - R18's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). The admission Minimum Data Set (MDS) dated [DATE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-30 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 34 resident. The sample included 13 residents with five residents reviewed for baseline care plan. Based on observations, record reviews, and interviews, the facility failed to develop a baseline care plan which included fall interventions for Resident (R)181. This deficient practice placed her at risk for accidents and injury. Findings Included: - The electronic medical record (EMR) documented the following diagnosis for R181: dementia (progressive mental disorder characterized by failing memory, confusion), repeated falls, and difficulty walking. The Entry Tracking Minimum Data Set ( MDS) recorded R181 admitted to the facility on [DATE]. R181's admission MDS was in progress on date of review on 03/30/22. An admission Fall Assessment completed on 03/22/22 indicated R181 was a fall risk related to poor balance and gait. A review of R181's Initial Care Plan dated 03/22/22 revealed that she was to be evaluated by physical and occupational therapy for falls and she was 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 · D2022-03-30 · 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 electronic medical record for R2 documented diagnoses of end stage renal disease (ESRD-medical condition in which the kidneys cease functioning on a permanent basis) and dependent on renal dialysis dated 06/08/21. The Significant Change Minimum Data Set (MDS) dated [DATE] documented R2 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. He required limited to extensive assist of one staff for his activities of daily living (ADLs). He required the use of a mechanical lift for transfers and a wheelchair for mobility. Dialysis was not indicated for R2 while not a resident nor while a resident. The Quarterly MDS dated 03/15/22 documented R2 had a BIMS score of 15 which indicated intact cognition. He required limited to extensive assist of one staff for ADLs. He used a wheelchair for mobility that he self-propelled. He required dialysis treatment. The ADL Care Area Assessment (CAA) dated 06/28/21 documented R2 required extensive assist of one to two staff with his ADLs.…
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 before2022-03-30 · 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 identified a census of 34 residents. The sample included 13 residents with five reviewed for bathing. Based on observations, record reviews, and interviews, the facility failed to provide consistent bathing per the residents' preferences and bathing schedules for Residents (R) 18, and R25. This deficient practice placed the resident at risk for poor hygiene and impaired psychosocial well-being. Findings included: - R18's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented R18 was totally dependent of two staff members for activities of daily living…
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 before2022-03-30 · 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 34 residents. The sample included 13 residents, with seven residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure staff utilized the care planned interventions for Resident (R) 18 to prevent falls and failed to implement appropriate interventions aimed at preventing falls for R25, who was identified as a high fall risk. The facility failed to implement preventative fall measures upon admission as well as appropriate fall interventions immediately after a fall for R181, who was at risk for falls. These deficient practices placed residents at risk for injury related to falls. Findings included: - R18's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), and osteoarthritis (degenerative changes to one or many joints characterized by…
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 · D2022-03-30 · tag F0691 — failed to provide colostomy / ostomy care — isolatedProvide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 34 residents. The sample included 13 residents. One resident, Resident (R) 129, was sampled for ileostomy (a surgical formation of an opening through which fecal matter emptied) care. Based on observation, record review and interview, the facility failed to ensure a physician's order for ileostomy care (when to change, how often to change, how often to check the ostomy) and appropriate application of the necessary cares. This deficient practice left R129 at risk for complications related to the ileostomy such as infection and skin breakdown. Findings included: - The electronic medical record (EMR) for R129 documented diagnoses of surgical aftercare following surgery on the digestive system, and ileostomy. R129's admission Minimum Data Set (MDS) was in progress as she was admitted on [DATE]. R129's Care Area Assessment was in progress. The Ileostomy Care Plan initiated 03/28/22 documented/directed staff to: assess stoma (an artificial opening in the abdomen) site and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-30 · 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 identified a census of 34 residents. The sample included 13 residents. Four residents were sampled for respiratory care. Based on observation, record review, and interview, the facility failed to ensure that staff provided the necessary respiratory care and services when staff failed to properly change, dated and stored oxygen (O2) tubing when not in use for resident (R)130 and R20, which left these resident at risk for unwarranted respiratory complications. Findings included: - The electronic medical record (EMR) for R130 document diagnoses of chronic obstructive pulmonary disease (COPD-a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), pulmonary fibrosis ( a lung disease that occurs when lung tissue becomes damaged an scarred, and pneumonia (inflammation of the lungs). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15. He required extensive assistance of one…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-03-30 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 34 residents. The sample included 13 residents. One resident was sampled for dialysis (the process of removing excess water and wastes from the blood in people whose kidneys no longer function on their own) care. Based on observation, record review and interview, the facility failed to ensure that Resident (R)2 had a physician's order for dialysis and failed to ensure critical information such as the name and location of the dialysis center, a contact number, the time of treatment and transportation to/from the dialysis clinic was documented on R2's clincial record. This deficient practice left R2 at risk for improper care and treatment. Findings included: - The electronic medical record (EMR) for R2 documented diagnoses of end stage renal disease (ESRD) (ESRD-medical condition in which the kidneys cease functioning on a permanent basis) and dependent on renal dialysis dated 06/08/21. The Significant Change Minimum Data Set (MDS) dated [DATE] documented R2 had 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.
- No harm found · Ccited before2025-08-12 · 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 36 residents. The sample included 12 residents. Based on record review and interviews, the facility failed to submit accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ - Staffing Data Report) when the facility failed to submit accurate weekend staffing coverage hours. This placed the residents at risk for unidentified and ongoing inadequate staffing. Findings included: - A review of the facility's submitted PBJ data from 04/01/24 through 03/31/25 indicated the facility triggered for excessively low weekend staffing for Fiscal Year (FY) Quarter One 2024 (10/01/24 to 12/31/24) A review of the facility's working schedule, time sheets/punches, and posted staffing hours indicated no gaps or loss of hours. On 08/12/25 at 11:20 AM, Administrative Nurse D stated the facility used agency staff during the triggered period, and the time may not have been documented appropriately on the reporting. The facility's Payroll-Based Journaling policy, revised 10/2023, indicated staffing and census information will be…
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 THE ENSIGN GROUP — 342 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 | 3.2 | +0.8 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 4 of 5 | 2.7 | +1.3 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 341 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 341; lowest-rated first.
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 |
|---|---|---|---|
| BROOKS, MICHAEL | Individual | W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | since 10/01/2023 |
| BURTON, SPENCER | Individual | CORPORATE DIRECTOR | since 10/01/2023 |
| BURNAM, SOON | Individual | CORPORATE OFFICER | since 10/01/2023 |
| FITCH, CRAIG | Individual | CORPORATE OFFICER | since 10/01/2023 |
| LEWIS, CORWIN | Individual | CORPORATE OFFICER | since 10/01/2023 |
CMS files one row per role, so the 6 rows in the source record cover these 5 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.
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 175159. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-12, 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.