Louisburg Healthcare And Rehabilitation Center
1200 S Broadway St, Louisburg, KS 66053 · For profit - Limited Liability company · 60 certified beds · (913) 837-2916 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- it has 1 actual-harm citation
- a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $19,218 in federal fines (most recent 2023-11-08)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (1/5)
- about 20% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 1 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 | 1 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 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 | 31.9% | 17.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 0.0% | 4.9% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.2% | 2.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.3% | 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 | 1.6% | 4.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 28.7% | 16.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 24.3% | 23.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 94.2% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.3% | 4.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 20.8% | 22.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.7% | 18.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.5% | 1.9% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 92.9% | 73.8% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 23.5% | 22.4% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 21.3% | 11.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.81 | 1.80 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.73 | 2.13 | 1.80 | typical |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
42.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 28 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 28.6% 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 42 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 0.60 therapist hours per resident per day in 2026Q1 — more than 88% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 17% 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 | 42.2%CMS range 26.7–60.3 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.6%CMS range 8.3–16.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 28.6% | 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 | 26.2% | 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 | 26.2% | 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 | 58.3% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 8.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.5%CMS range 3.7–11.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.14 | 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 60 beds and averages 52.3 residents a day — about 87% occupied, or roughly 8 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 3.49 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 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 3.10 hrs/resident/day on weekends vs 3.65 on weekdays — 15% thinner on weekends. RN hours go from 0.41 to 0.25 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.
21 citations, most serious first. The 11 most serious are shown; the remaining 10 are one tap away and print in full.
- Actual harm · Gcited before2022-01-05 · 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 - Review of resident R7 Physician Order Sheet, dated 12/30/21, revealed diagnoses included Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), dementia (progressive mental disorder characterized by failing memory, confusion) and abnormality of gait and mobility. - The Quarterly Minimum Data Set (MDS), dated [DATE], assessed the resident Brief Interview for Mental Status (BIMS) of 15, that indicated the resident had normal cognition. The resident required supervision for transfers and ambulated with a walker. The resident's balance was always steady and the resident had no impairment in functional range of motion in her upper or lower extremities. The Significant Change Minimum Data Set, (MDS) dated [DATE], assessed the resident had severe cognitive impairment, required extensive assistance of two persons for transfers, toileting and personal hygiene, and was dependent on one staff for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-08-26 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 54 residents, one kitchen and one kitchenette. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions, to prevent the potential for food borne bacteria. This placed the residents at risk of food borne illnesses. Findings included:- During an initial tour of the kitchen on 08/24/25 at 09:23 AM, observation revealed the following areas of concern: 1. One black two-tiered cart utilized to hold milk, juice, clean cups, and other supplies at mealtimes had food debris on both tiers. 2. One three-tiered blue, plastic cart utilized to deliver food to residents at mealtimes had food debris on all tiers. 3. One two-tiered black, plastic cart utilized for holding desserts during mealtimes had several dried-on sticky areas. 4. The inside of a two-doored reach-in refrigerator had a dried-on red liquid on the bottom along with food debris. 5. The inside of a two-doored reach-in refrigerator contained three one-gallon containers of dressings with dried-on dressing around the top and sides of 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 · Fcited before2025-08-26 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 54 residents; the sample included 16 residents. Based on interviews, record reviews and observation, the facility failed to ensure a safe and sanitary environment in all areas of the facility including the laundry area. This deficient practice placed the residents at risk for contaminated laundry.Findings included:- During an observation on 08/25/2025 at 08:15 AM, the ceiling in clean linen processing room had paint flaking and missing in multiple areas above the resident's clean laundry. The clean linen folding counter was cluttered with items that were not resident clean laundry, that included a staff purse, a laptop, and a desk organizer with pens/pencils/scissors.During an observation on 08/25/25 at 08:30 AM, the dirty laundry washing area was cluttered and backed up with resident linen and clothes in bags that were stacked on the floor that blocked the staff hand-washing sink, the eye-wash station, and the washer laundry-soap refill. Multiple areas of the ceiling had paint chipped and missing, and the wall on the dryer side had multiple areas…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-08-26 · tag F0552 — patternEnsure that residents are fully informed and understand their health status, care and treatments.
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 54 residents; the sample included 16 residents. Based on interview, observation, and record review, the facility failed to inform Resident (R) 4, R8, R18, R43 and R49 and/or their representative regarding the risks related to psychotropic (alters mood or thoughts) medications. These practices had the potential to lead to uninformed decisions regarding treatment.Findings included:- Review of the Electronic Health Record (EHR) for R4 included diagnoses of altered mental status (a change in a person's level of consciousness, awareness, and cognitive function), metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R4’s…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-26 · 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 reported a census of 54 residents. The sample included 16 residents including one resident reviewed for dignity. Based on observation, interview, and record review, the facility failed to show respect and dignity to one Resident (R) 10 when staff left the window-blinds open during cares. This placed the resident at risk for impaired dignity and embarrassment. Findings included:- Review of R10's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion).R10's admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. She was frequently incontinent of bowel and bladder and was dependent on staff for toileting.The Care Area Assessments, dated 05/08/25, lacked analysis of findings.R10's Quarterly MDS, dated 08/08/25, documented that the resident had a BIMS score of three, indicating severe cognitive…
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 · D2025-08-26 · tag F0636 — isolatedAssess 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 54 residents; the sample included 16 residents. Based on observation, interview, and record review the facility failed to complete a thorough Minimum Data Set (MDS) for Resident (R)10, when staff did not complete the analysis of findings for the triggered Care Area Assessments (CAA). This placed the resident at risk for impaired care due to unidentified care needs. Findings included:- R10's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion).R10's admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. She was frequently incontinent of bowel and bladder and was dependent on staff for toileting. The Care Area Assessments, dated 05/08/25, lacked analysis of findings. R10's Care Plan, revised 06/11/25, instructed staff the resident was incontinent of bowel and bladder 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 · D2025-08-26 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 54 residents; the sample included 16 residents. Based on interviews, record reviews and observation, the facility staff failed to implement adequate 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) personal protective equipment (PPE- gowns, face shields and/or eyeglasses/goggles, and gloves) for Resident (R) 8 while accessing her gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) for flushing. The facility failed to ensure a sanitary environment in the laundry area. This deficient practice placed the resident at risk infections related to lack of proper PPE usage and possible contaminated laundry.Findings included:- During an observation on 08/25/2025 at 08:15 AM, the ceiling in clean linen processing room had paint flaking and missing in multiple areas above the resident's clean laundry. The clean linen folding counter was cluttered with items that were not 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 · Fcited before2023-10-30 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 33 residents. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria. Findings included: - During an initial tour of the kitchen on 10/25/23 at 11:31 AM, the following areas of concerns identified: 1. The stationary can opener had a dried-on, sticky substance on the tip. 2. A half-gallon of sour cream in the reach-in refrigerator was undated. 3. Two reach-in refrigerators had food debris on the bottom. 4. There were two half-gallon jugs of apple juice stored directly on the floor of the dry storage room, without a barrier. 5. A three-gallon box of grape juice and a three-gallon box of cranberry juice for the juice machine stored directly on the kitchen floor, without a barrier. 6. Four pans stored on a shelf beneath one prep table had food debris in the lip of the pans. 7. Two food scales, used to weigh food, had a layer of a dust type substance. 8. The shelf over the range contained 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 · E2023-10-30 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 33 residents. Based on interview and record review, the facility failed to provide residents opportunities to change their declinations for the influenza/pneumococcal vaccine. Findings included: - Review of Resident (R) 23's electronic medical record Immunization task revealed consent refused for influenza pneumonia and COVID. A COVID declination was signed by the resident on 10/27/22. A declination for pneumococcal and influenza vaccine was signed by the resident on 11/04/21. Review of the Annual Minimum Data Set (MDS) dated [DATE], indicated the resident had a Brief Interview for Mental Status (BIMS) score of 08, that indicated moderately impaired cognition. Review of R 15's electronic medical record, under the Immunization tab contained undated entries which revealed the resident declined the pneumococcal vaccination once and the influenza vaccine three times. A pneumococcal vaccination declination was signed by the resident on 07/29/22. The resident signed an agreement for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-30 · tag F0887 — patternEducate 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
The facility reported a census of 33 residents. Based on interview and record review, the facility failed to provide residents opportunities to change their declinations for the COVID vaccination. Findings included: - Review of Resident (R)23's electronic medical record, under the Immunization task tab, revealed an entry consent refused for the COVID vaccination with the entry undated. A COVID declination was signed by the resident on 10/27/22. Review of R15's electronic medical record, under the Immunization tab contained an undated entry which revealed the resident declined the COVID vaccination. Further review of the medical record revealed a signed Covid declination undated, and three signed declinations dated 06/02/21, 05/04/21, and 12/23/21. Review of R13's electronic medical record, under the Immunization tab contained an undated entry that the resident declined the COVID vaccine. Further review of the electronic medical record revealed the resident signed a COVID declination dated 12/17/21 and 10/10/22. Interview, on 10/30/23 at 02:45 PM, with Administrative Nurse E,…
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 · D2023-10-30 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 33 residents with 16 residents selected for review, which included two residents reviewed for range of motion. Based on observation, interview, and record review, the facility failed to provide consistent restorative services to one Resident (R)6 of the two residents reviewed for range of motion. Findings included: - Review of Resident (R)6's Physician Order Sheet, dated 10/01/23, revealed diagnoses included cerebral vascular accident (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), left hemiplegia (paralysis of one side of the body muscular weakness of one half of the body), dysphagia (swallowing difficulty), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), major depressive disorder (major mood disorder), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 10 citations
- Potential for harm · Dcited before2023-10-30 · 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 reported a census of 33 residents, with 16 residents sampled, including six residents reviewed for accidents. Based on interview, record review, and observation, the facility failed to ensure appropriate interventions initiated for one Resident (R)12, and failed to utilize appropriate interventions to prevent a fall for R 139, which resulted in a non-injury fall when staff failed to utilize a gait belt while toileting the resident. Findings included: - Review of Resident (R)139's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Five-day Minimum Data Set (MDS), dated [DATE], documented the resident admitted to the facility on [DATE] from an acute care hospital. His Brief Interview for Mental Status (BIMS) score was six, which indicated severe cognitive impairment. He required extensive assistance of two staff for toileting and transfers and required limited assistance of two staff for ambulation. His balance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-01-05 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 39 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions to prevent the spread of food borne illnesses to the residents of the facility. Findings included: - An environment tour of the facility on 01/04/22 at 11:36 AM, noted the following areas of concern: 1. The dish drying rack by the dishwasher had multiple areas of rust, making it unable to sanitize. 2. The covered trash can by the hand washing sink had dried food substances on the lid and the front of the trash can. 3. The juice machine grate had multiple rusty areas, making it unable to sanitize. 4. The inside of the toaster had a heavy build- up of crumbs. 5. The condiments container had crumbs and food debris in the bottom of all six compartments. 6. The shelf underneath the steam table where the pans and lids stored for the steam table, had a build- up of food debris. 7. Three skillets had the non-stick coating missing from the cookware. On 01/05/22 at 09:19 AM, dietary staff BB stated, the toaster 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 · Fcited before2022-01-05 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — the official record, unedited, may be distressing
The facility had a census of 39 residents. Based on observation, record review, and interview, the facility failed to provide a sanitary environment for residents and staff in the kitchen. Findings included: - On 01/04/22 at 11:36 AM, observation revealed an accumulation of built-up grime, dirt and food debris on the floor of the kitchen including underneath the appliances, shelving, and around the perimeter of the kitchen floor. On 01/05/22 at 09:19 AM, Dietary staff BB stated, staff are to clean the kitchen floor at least twice daily. The staff are not getting the floor as clean as they should be. The facility policy for Cleaning and Sanitation of Dining and Food Service Areas, dated 2017, included: The nutrition and food services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. The facility failed to provide a safe and sanitary environment for the residents and staff related to the dirt, debris on the kitchen floor, appliances, shelving and parameter of the floor.
- Potential for harm · D2022-01-05 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 39 residents. Based on observation, record review, and interview the facility failed to maintain a comfortable room temperature for one resident's room. Findings included: - Interview, on 12/29/21 at 09:30 AM, with alert resident (R)13, revealed his heating unit malfunctioned for the past two days and he was cold and uncomfortable. The resident stated he had notified an unidentified staff member two days ago. He stated the heater ran for a while two days ago, then shut off. Observation, on 12/29/21 at 09:30AM, revealed a room temperature of 66 degrees Fahrenheit. The heating unit did not turn on when the power switch attempts to be activated. The resident positioned in his bed, wrapped in a thick blanket. Interview, on 12/29/21 at 09:45 AM, with Maintenance staff U, revealed staff did not notify him of the problem. Maintenance staff U determined the breaker on the plug needed reset. Maintenance staff U reset the breaker and the unit produced heat. The facility policy Safe and Homelike Environment, dated 10/25/19, instructed staff to strive to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-01-05 · 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 39 residents with 15 residents sampled. Based on interview and record review, the facility failed to complete an accurate quarterly assessment for one Resident (R)135, regarding falls. Findings included: - The Physician Order Sheet (POS), dated 07/21/21, documented Resident (R)135 had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. The resident had no falls since admission. The Falls Care Area Assessment, dated 07/04/21, documented the resident was at a high risk for falls. The discharge MDS, dated 07/26/21, documented the staff assessment for cognition revealed modified independence for cognition. She had no falls since the prior assessment. The falls care plan, dated 07/03/21, instructed staff the resident was at a high risk for falls and to anticipate…
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 · D2022-01-05 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY - Review of resident R7 Physician Order Sheet, dated 12/30/21, revealed diagnoses included Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), dementia (progressive mental disorder characterized by failing memory, confusion) and abnormality of gait and mobility. The Quarterly Minimum Data Set (MDS), dated [DATE], assessed the resident Brief Interview for Mental Status (BIMS) of 15, that indicated the resident had normal cognition. The resident required supervision for transfers and ambulated with a walker. The resident's balance was always steady, and the resident had no impairment in functional range of motion in her upper or lower extremities. The Significant Change Minimum Data Set, (MDS) dated [DATE], assessed the resident had severe cognitive impairment, required extensive assistance of two persons for transfers, toileting and personal hygiene, and was dependent on one staff for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-01-05 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 39 residents with 15 residents included in the sample, including four residents reviewed for Activities of Daily Living (ADLs). Based on observation, interview, and record review, the facility failed to ensure appropriate personal hygiene was provided for two dependent Residents (R)33, regarding facial shaving and R 29, regarding nail care. Findings included: - The Physician Order Sheet (POS), dated 12/30/21 for Resident (R)33, documented a diagnosis of Parkinson's (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed the resident had severe cognitive impairment. She did not refuse cares and required total assistance of two staff for personal hygiene. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 05/07/21, did…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-01-05 · 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 39 residents with 15 selected for review which included three residents reviewed for skin conditions/non-pressure wounds. Based on observation, interview and record review, the facility failed to provide wound care in a sanitary manner to one resident (R)7's vascular heel ulcer (a wound caused by poor circulation.) Findings included: - Review of Resident R7 Physician Order Sheet, dated 12/30/21, revealed diagnoses included Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), dementia (progressive mental disorder characterized by failing memory, confusion) and abnormality of gait and mobility. The Quarterly Minimum Data Set (MDS), dated [DATE], assessed the resident had a Brief Interview for Mental Status(BIMS) score of 15 , that revealed normal cognition. The resident required supervision for bed mobility, transfers, ambulation, toileting and personal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-08-26 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 54 residents. Based on observation, interview, and record review, the facility failed to ensure the posted daily nurse staffing sheets included accurate and identifiable information to include the daily licensed and unlicensed staff actual worked hours.Findings included:- Observed on 08/24/25 at 08:15 AM, the facility's posted daily staffing sheet did not list the actual number of hours worked. Also posted were the daily staffing sheets for 08/23/25 and 08/22/25, which also lacked the actual hours worked.Observed on 08/26/25 at 11:09 AM, the actual hours worked were not posted on the daily staffing sheet for 08/26/25. Record review for the month of August 2025 revealed the following daily staffing sheets did not list the actual hours worked: 08/20, 08/19, 08/17, 08/16, 08/12, 08/11, 08/10, 08/05, 08/08, 08/07, 08/06, 08/05, 08/04, 08/03, 08/02, and 08/01.During an interview on 08/26/25 at 08:30 AM, Administrative Staff A stated that if the actual hours worked was the same as the total number of hours worked, she did not rewrite it on the daily…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-08-26 · 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 54 residents. Based on interview and record review, the facility failed to electronically submit complete and accurate staffing information to the Federal regulatory agency through Payroll-Based Journaling (PBJ) when the facility failed to accurately submit hourly staffing data for all weekend personnel. The facility failed to submit complete and accurate staffing information to the Federal regulatory agency through PBJ when the facility failed to accurately submit hourly staffing data for all weekend personnel.Findings included: - Review of the PBJ Staffing Data Report for Fiscal Year (FY) for Quarter 4 - 2024 (July 1 - September 30), FY Quarter 1-2025 (October 1 - December 31), and FY Quarter 2 - 2025 (January 1 - March 31) the facility failed to have sufficient staffing for the weekends.Review of the Nursing Schedule and Payroll Data Sheets for the weekends of the above months revealed the facility had sufficient weekend staff coverage.During an interview on 08/26/25 at 08:30 AM, Administrative Staff A stated that reported time had not been…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$19,218 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $19,218 — penalty dated 2023-11-08
- Medicare payment denial — starting 2023-11-28 for 2 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to RECOVER-CARE HEALTHCARE — 27 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.4 | +0.6 vs chain |
| Health inspection | 4 of 5 | 2.5 | +1.5 vs chain |
| Staffing | 2 of 5 | 2.4 | -0.4 vs chain |
| Quality measures | 1 of 5 | 3.1 | -2.1 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 LLC | Organization | DIRECT OWNERSHIP INTEREST | since 02/28/2025 |
| MRC SNF MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/04/2025 |
| PETERSEN, MARK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/28/2025 |
| PETERSON, EMMA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 02/28/2025 |
| WOODRUM, ASHLEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2022 |
| AGGBF TRUST | Organization | ADP OF THE SNF | since 02/28/2025 |
| BHNV PROPERTY HOLDINGS 2 LLC | Organization | ADP OF THE SNF | since 02/28/2025 |
| BK 5 HUD FACILITIES LLC | Organization | ADP OF THE SNF | since 05/28/2025 |
| KANSAS SNF HOLDINGS LLC | Organization | ADP OF THE SNF | since 02/28/2025 |
| LOUISBURG SNF REALTY LLC | Organization | ADP OF THE SNF | since 05/28/2025 |
| MAD FAMILY HOLDINGS LLC | Organization | ADP OF THE SNF | since 02/28/2025 |
| NATR TRUST | Organization | ADP OF THE SNF | since 02/28/2025 |
| RARMNA HOLDINGS LLC | Organization | ADP OF THE SNF | since 02/28/2025 |
| RATR TRUST | Organization | ADP OF THE SNF | since 02/28/2025 |
| RECOVER CARE HEALTHCARE PROPERTY 2 LLC | Organization | ADP OF THE SNF | since 02/28/2025 |
| RNR HOLDINGS LLC | Organization | ADP OF THE SNF | since 02/28/2025 |
| WETR TRUST | Organization | ADP OF THE SNF | since 02/28/2025 |
CMS files one row per role, so the 20 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
14 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $868K paid to related parties — landlords or management companies under common ownership — equal to about 20% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in KS
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Kansas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175238. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-26, 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.