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Riverview Estates

202 S Washington Street, Marquette, KS 67464 · Non profit - Corporation · 36 certified beds · (785) 546-2211 Medicare & Medicaid certified

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Flagged for abuseBehavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$35,839 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (5/5)
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $35,839 in federal fines (most recent 2025-06-02)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its facility-reported quality-measure rating is low (1/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 1 of 5

Worth a closer look. This home's staffing rating runs 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
605 W Lincoln St · (785) 227-3371 · Call to confirm hours
Pharmacy
605 W Lincoln St · (785) 227-3374 · Call to confirm hours
Grocery
102 S Washington St · (785) 546-2271 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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 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 fell from 4 to 1 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.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased27.2%17.9%15.4%worse
Long-stay residents who lose too much weight2.4%4.9%5.4%better
Long-stay residents with a catheter left in their bladder8.6%1.6%0.9%worse
Long-stay residents with a urinary tract infection8.0%2.9%2.0%worse
Long-stay residents with depressive symptoms4.1%6.5%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury5.9%4.3%3.3%worse
Long-stay residents whose ability to walk worsened24.5%16.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication15.5%23.2%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.5%95.3%typical
Long-stay residents with pressure ulcers5.4%4.4%4.7%worse
Long-stay residents with worsening bladder/bowel control33.9%22.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table29.2%18.1%17.1%worse
Long-stay hospitalizations per 1,000 resident days2.671.801.67worse
Long-stay outpatient ER visits per 1,000 resident days4.842.131.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

48.9% 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.

48.9%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
0.29U.S. median 0.31
Therapy hours / resident / day
0.23hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy

Therapy staffing: this home’s payroll records show 0.29 therapist hours per resident per day in 2026Q1 — more than 44% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF48.9%CMS range 35.2–65.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 6.8–16.010.7%Oct 2022–Sep 2024no 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS 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 settingnot 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 dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened8.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.9%CMS range 4.2–14.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.101.02Oct 2022–Sep 2024CMS 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

0.81
RN hours/ resident / day
0.55
LPN hours/ resident / day
2.99
Aide hours/ resident / day
4.35
Total nurse hours/ resident / day
0.56
RN hoursweekends
51.3%
Total nursing turnover
28.6%
RN turnover

How full it usually is: this home is certified for 36 beds and averages 29.8 residents a day — about 83% occupied, or roughly 6 beds typically open. It usually has some room. 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 4.35 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.81 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.99 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.81 hrs/resident/day on weekends vs 4.57 on weekdays — 17% thinner on weekends. RN hours go from 0.90 to 0.56 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 51% 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

11
deficiencies at the latest standard inspection (2025-03-20)
4
at the previous standard inspection (2023-06-08)

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.

ABCDEFGHIJKL

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.

25 citations, most serious first. The 12 most serious are shown; the remaining 13 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-03-20 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 23 residents. The sample size included 12 residents, with 12 residents reviewed for neglect. Based on record review and interview, the facility failed to prevent the neglect of Resident (R) 26, when staff failed to timely and competently assess and provide care for R26, who had a known history of sepsis (a life-threatening systemic reaction that developed due to infections which cause inflammation throughout the entire body). On 01/05/25 at 06:58 PM, R26 struggled to talk and drink liquids. Licensed Nurse (LN) H contacted the on-call physician and reported R26 acted similar to the last time R26 was septic. Based on this information, the physician ordered one gram of Rocephin (an antibiotic) every 24 hours for seven days and stated if R26 did not show any signs of improvement, or her condition worsened, then LN H was to send R26 to the Emergency Room. On 01/06/25 at 02:55 AM, R26 had oxygen on at two liters per minute, with shallow, labored respirations. R26's skin was pale and moist…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-06-02 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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 27 residents, with three residents reviewed for abuse, neglect, and exploitation. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 2 and R1 remained free from verbal and mental abuse. This placed R2 and R1 at risk for continued abuse, embarrassment, humiliation, and decreased quality of life due to impaired psychosocial well-being. Findings included: - R2 ' s Electronic Medical Record (EMR) documented R2 had diagnoses of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and pain. R2's Quarterly Minimum Data Set, (MDS) dated [DATE], documented R2 had a Brief Interview for Mental Status score of 15, which indicated intact cognition. The MDS documented R2 had an indwelling urinary catheter (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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · Fcited before2025-03-20 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 had a census of 23 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to properly date opened bags of food with the open date and the expiration date. This practice placed the 23 residents at risk for foodborne illness and poor-quality food. Findings included: - On 03/13/25 at 08:20 AM, an inspection of the facility kitchen cold storage revealed the #4 upright freezer had seven opened, undated bags of frozen vegetables and potato items. The #5 freezer contained an opened box of hamburger patties with the plastic bag open to the air and undated. On 03/13/25 at 08:20 AM, Dietary Staff BB verified the bags were undated or the date was not readable. She stated the marker staff used for frozen foods was not appropriate as the ink rubbed off. The facility's Food Receiving and Storage policy, dated October 2017, stated foods would be received and stored in a manner that complied with safe food handling practices. The policy stated all foods stored in the refrigerator or freezer would be covered, labeled, 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-03-20 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 23 residents. The sample size included 12 residents. Based on observation, record review, and interview, the facility failed to adhere to infection control for enhanced barrier precautions (EBP - an infection control intervention designated to reduce transmission of resistant organisms that employs targeted gown and glove used during high contact resident care activities), for Resident (R) 13 who had Influenza A (a contagious viral infection of the nose, throat and lungs that is spread from person to person through respiratory droplets). This placed the residents at increased risk for infection. Findings included: - On 03/13/25 at 09:30 AM, observation revealed License Nurse (LN) I entered the room of R13, who was on Droplet Precautions EBP. Observation revealed a sign posted on the resident's door of the resident's room giving instruction on personal protection equipment (PPE - gown and gloves). The PPE equipment and supplies were located in an over-the-door hanging container in the resident's room. Continued observation revealed LN I entered 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-20 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 23 residents. Based on observation, interview, and record review, the facility failed to perform background checks as required for four employees. The employees were allowed access to residents without knowing if they had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. This deficient practice placed the 23 residents of the facility at risk for potential abuse, neglect, or exploitation. Findings included: - On 03/18/25 a review of staffing for background checks for facility staff was completed. Upon request and review the facility was unable to provide evidence a criminal background check had been completed before four employees began working around and with residents. The facility records revealed the following staff started employment at the facility before the background checks returned: Certified Nurse Aide (CNA) N started on 07/09/22 and the background check was not verified until 02/04/24. CNA O started on 01/24/24 and the background check was not verified until 02/12/24.…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-20 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop 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 had a census of 23 residents. The sample includes 12 residents, with seven residents reviewed for immunizations, Resident (R) 5, R10, R11, R13, R16, R21, and R22, to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interviews, the facility failed to offer, or obtain an informed declination or a physician-documented contraindication for the pneumococcal PCV20 vaccination per the latest guidance from the Centers for Disease Control and Prevention (CDC). This placed the residents at risk for pneumococcal infection and related complications. Findings included: - Review of R10, R11, R13, R16, and R21 clinical medical records lacked evidence the facility or the resident representative received or signed a consent to receive or informed declination for the pneumococcal vaccine PCV20. Review of R5's electronic health record revealed the resident was admitted to the facility 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-20 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 23 residents. The sample size included 12 residents. Based on record review and interview, the facility failed to notify Resident (R) 26's physician or family when staff noted an abnormal bulge in R26's right abdomen on 01/03/25. The facility nursing staff also failed to notify the physician on 01/06/25 when R26 had a further deterioration in condition with shallow, labored respirations. R26's skin was pale and moist to the touch, and she had coarse lung sounds throughout. R26 did not respond when staff called her name, nor did she communicate with staff. LN H failed to call the physician or send R26 to the ER at that time. This deficient practice placed R26 at risk for serious health consequences. Findings included: - R26's Electronic Medical Record (EMR) documented diagnoses of sepsis, ulcer of the esophagus (the tube that carries food and liquids from the mouth to the stomach) with bleeding, fracture (broken bone) of shaft of the right humerus (upper arm bone), and age-related…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-20 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 had a census of 23 residents. The sample included 12 residents. Based on interviews and record review, the facility failed to notify the State Long term Care Ombudsman (LTCO) of Resident (R)13's facility-initiated discharge to the hospital. This placed R13 at risk for impaired rights. Findings included: - R13's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) with behavioral disturbance, arteriosclerotic heart disease (ASHD, is a condition where the arteries that supply blood to the heart become narrowed and hardened due to buildup of plaque, a sticky substance), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R13's Significant Change Minimum Data Set (MDS), dated [DATE], recorded R13 had severe cognitive impairment. The MDS recorded she required extensive staff assistance with transfers and activities of daily living (ADL). The MDS documented the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-20 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 23 residents. The sample included 12 residents, with two residents reviewed for discharge. Based on observation, record review, and interview, the facility failed to provide Resident (R) 13 with written information regarding the facility's bed hold policy when she was transferred to the hospital. This placed the resident at risk of not being permitted to return and resume residence in the nursing facility. Findings included: - R13's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) with behavioral disturbance, arteriosclerotic heart disease (ASHD - is a condition where the arteries that supply blood to the heart become narrowed and hardened due to buildup of plaque, a sticky substance), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R13's Significant Change Minimum Data Set (MDS), dated [DATE], recorded R13 had 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-20 · tag F0661 — isolated
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 23 residents. The sample included 12 residents. Based on record review and interview, the facility failed to develop a discharge summary that included a complete recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay and post-discharge plan for Resident (R) 27. This placed the resident at risk for receiving inadequate care. Findings included: - R27's Electronic Medical Record (EMR) revealed the resident admitted to the facility on [DATE]. R27's admission Minimum Data Set (MDS), dated [DATE], documented R27 required limited staff assistance with activities of daily living (ADL). The MDS documented there are active discharge plans in place for returning R27 to return to the community. The Activities of Daily Living (ADLs) Care Area Assessment (CAA), dated 12/26/24, documented the resident was recently hospitalized for treatment of pneumonia and would receive physical therapy and occupational therapy. The CAA documented…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-20 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 23 residents. The sample included 12 residents with one reviewed for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). Based on observation, interview, and record review, the facility failed to provide Resident (R) 11 a device to secure the catheter tubing to keep it from pulling and causing discomfort. This deficient practice placed R11 at risk for pain or injury related to the catheter use and R11 developed two open sores related to the catheter rubbing. Findings included: - R11's Electronic Medical Record (EMR) documented diagnoses of an open wound of the penis (male organ with urethra tube which carries urine to outside the body), pain, and Urinary Tract Infection (UTI - an infection in any part of the urinary system). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS documented R11 required maximum staff assistance 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-20 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice 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 had a census of 23 residents. The sample included 12 residents with one reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure coordinated care and services provided by the facility with the care and services provided by hospice for Resident (R) 13. This placed the residents at risk for inadequate end-of-life care. Findings included: - R13's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) with behavioral disturbance, arteriosclerotic heart disease (ASHD - is a condition where the arteries that supply blood to the heart become narrowed and hardened due to buildup of plaque, a sticky substance), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · F2023-06-08 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to employ a full time certified dietary manager for the 31 residents who resided in the facility and received meals from the facility kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 06/05/23 at 11:30 AM, review of the posted Noon Meal Sheet revealed it consisted of crumb-topped baked fish, tater tots, Brussel sprouts, coconut creme pie and garnished lemon wedge. On 06/05/23 at 9:00 AM, observation revealed Dietary Staff (DS) BB in the kitchen overseeing the preparation of the noon meal. On 06/05/23 at 09:10 AM, DS BB verified she was uncertified. On 06/08/23 at 10:00 AM, Administrative Staff A verified Dietary Staff BB had no dietary manager certification; Dietary Staff BB had completed the course but had not taken the test. The facility's Food and Nutrition Services Staff Policy, revised October 2017, documented the food services department would be staffed by food and nutrition services…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-08 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 had a census of 31 residents. The sample included 12 residents with one reviewed for Preadmission Screening and Resident Review (PASSAR-short series of questions designed to determine whether or not a more in-depth assessment for mental health services is required). Based on observation, record review and interview the facility failed to conduct a PASSAR Level II (an in-depth assessment for the purpose of determining whether the individual requires the level of services provided by a nursing facility or the level of services provided in a specialized program for persons with mental illness or developmental disabilities) for Resident (R)18 when it was noted on the PASSAR I R18 needed further evaluation (Level II). This placed the resident at risk for unmet needs. Findings included: - R18's Electronic Medical Record (EMR) documented R18 had diagnoses of paranoid schizophrenia (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking with a psychotic…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-08 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 31 residents. The sample included 12 residents with one reviewed for urinary tract infection (UTI-an infection in any part of the urinary system}. Based on observation, record review, and interview the facility staff failed to change gloves when providing incontinent cares for Resident (R) 16 and continued to provide care with the same soiled gloves. This placed R16 at risk for infection Findings included. - R16's Electronic Medical Record (EMR) documented R16 had diagnoses of UTI and retrocede (condition when the tissue wall which separates the rectum from the vagina is weakened and leads to the vaginal wall to bulge). R16's Quarterly Minimum Data Set (MDS), dated [DATE], documented R16 had a Brief Interview of Mental Status (BIMS) score of three, which indicated severely impaired cognition. The MDS documented the resident required extensive staff assistance with dressing, toilet use and independent with rest of activities of daily living (ADLs). The MDS noted R16 had a UTI. The UTI…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-08 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 31 residents. Based on observation, record review, and interview the facility kitchen staff failed to provide food prepared by methods that conserve nutritive value, flavor and appearance, when dietary staff failed to follow a recipe while preparing two residents' pureed diets. This placed the residents at risk for impaired nutrition. Findings included: - On 06/06/23 at 10:44 AM, Dietary Staff (DS) CC, with Dietary Manager (DM) BB overlooking, stated the facility had two residents with pureed diets, and one with a mechanical soft diet. DS CC placed three cups of diced chicken into the blender container with one cup chicken broth, one tablespoon (TB) thickener and blended the contents to consistency of pudding without following a recipe. DS CC placed it in a metal pan, covered, and placed on the steam table. Further observation revealed DS CC placed six ounces of peas, unmeasured water from the sink, one TB thickener, and blended to the consistency of pudding without following recipe. On 06/06/23 at 10:44 AM, DS CC verified she had not followed a recipe…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2021-10-28 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to prepare, store, distribute, and serve food under sanitary conditions for the 31 residents in the facility, who received their meals from the facility kitchen. Findings included: - On 10/19/21 at 08:10 AM, during initial tour, observation revealed the following: 2- eight by eight-inch square air vents located in front of exhaust hood and stove with rust stains noted on the grill. 2- eight by eight-inch square air vents located between the food preparation table and the dishwasher with rust stains noted on the grill. 1 - 24 inch by 24-inch square air vent located between the food preparation table and the hot warming well cart with brown greasy substance and gray fuzzy substance on the grill. The two foot by five-foot fluorescent light, located above the food preparation area with a three inch by five-inch section of the plastic light cover missing and the fluorescent bulbs exposed. Continued observation of the stove hood revealed 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-10-28 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 31 residents. Based on observations, interviews, and record review, the facility failed to provide comfortable sound levels to allow for privacy and unwanted noise for the overhead intercom paging system. This placed all residents at risk for unwanted noise/sound levels in the facility. Findings included: - On 10/26/21 at 01:20 PM and 03:00 PM, observation revealed the office staff made generalized announcements on the overhead paging system that started off as a shrill noise followed by the announcement that pertained to staff and not the residents. On 10/27/2021 at 09:58 AM, observation revealed the office staff announced on the overhead paging system, morning meeting activity room, morning meeting activity room. At 10:15 AM, observation revealed the office staff announced on the overhead paging system, Carol you have a call on 800, Carol you have a call on 800. At 10:56 AM, observation revealed the office staff announced on the overhead paging system, Monica call [NAME],…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-10-28 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 31 residents. The sample included 12 residents with one reviewed for pressure ulcers (PU) (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). Based on observation, interview, and record review, the facility failed to evaluate Resident (R) 11's PUs on her buttocks and toes each week from April to July 2021. Findings included: - R11's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 99, short and long term memory problems. The MDS documented R11 required staff supervision for eating, extensive assistance of two staff for most activities of daily living (ADLs) and total staff assistance for toileting. The MDS documented R11 weighed 104 pounds and had two unstageable pressure ulcers (ulcers covered with slough (dead tissue) or eschar (dead tissue) that were present on admission. Pressure relief measures included air mattress overlay on bed, repositioning, PU care, and nutrition program. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-10-28 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 31 residents. The sample included 12 residents with two reviewed for nutrition. Based on observation, record review, and interview, the facility failed to develop and implement effective nutritional interventions to prevent weight loss for one of five sampled residents, Resident (R) 20 who had a weight loss. Findings included: - R20's Physician Order Sheet, dated 09/02/21, documented diagnoses of major depression with psychotic features (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), dementia (progressive mental disorder characterized by failing memory, confusion), Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear.) The Annual Minimum Data Set (MDS), dated [DATE], recorded 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-10-28 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide 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 had a census of 31 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to collaborate care consistently with the treating dialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney) facility for one resident reviewed, Resident (R) 7. Findings included: - R7's Physician Order Sheet (POS), dated 10/21/21, documented diagnoses of hypertensive (elevated blood pressure) chronic kidney disease with stage five chronic kidney disease or end state renal disease (ESRD) (a condition where the kidney reaches advanced state of loss of function) , type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and heart failure. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R7 had intact cognition, independent with activities of daily living, had end stage renal disease, received insulin and dialysis treatment. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-10-28 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 31 residents. The sample included 12 residents with five review for unnecessary medications. Based on observation, interview, and record review the facility's consultant pharmacist failed to notify the Director of Nursing (DON), physician, or medical director of three of five sampled residents' medication irregularities. Resident (R) 5 had blood pressures lower than physician ordered parameters without physician notification, R11 had a physician order for Lorazepam (anti-anxiety drug), as needed (PRN), without a required stop date, and R23 had an inappropriate diagnosis for the use of Seroquel (class of medications used to treat psychosis and other mental emotional conditions). Findings included: - R5's Physician Order Sheet (POS), dated 10/21/21, documented diagnoses including congestive heart failure (CHF- progressive heart disease that affects pumping action of the heart muscles) and hypertension (high blood pressure). The Annual Minimum Data Set (MDS), dated [DATE], documented 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-10-28 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure 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 had a census of 31 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to notify the physician in a timely manner of Resident (R) 5's blood pressures which were lower than physician ordered parameters. Findings included: - R5's Physician Order Sheet (POS), dated 10/21/21, documented diagnoses including congestive heart failure (CHF- progressive heart disease that affects pumping action of the heart muscles), and hypertension (high blood pressure). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. The MDS documented R5 was independent with all activities of daily living (ADLs) and received antidepressant medication seven days of the lookback period. The Medication Care Plan, dated 08/11/21, documented nursing would assess and record effectiveness of drug treatment, intervene as needed, 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-10-28 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY - R23's Physician's Order, dated 09/07/21, recorded the following diagnoses of vascular dementia without behavior disturbance (progressive mental disorder characterized by failing memory and confusion), paranoid schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought with a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking) and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). The admission Minimum Data Set (MDS), dated [DATE], recorded the resident had severely impaired cognition. The MDS recorded the resident required limited staff assistance with bed mobility, dressing, toileting, personal hygiene, and walked independently without an assistive mobility device. The MDS further recorded the resident received an antipsychotic medication seven days a week. The Annual Care Area Assessment (CAA) 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-10-28 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to correctly prepare a pureed diet for two residents, Resident (R) 5 and R24. Findings included: - On 10/19/21 at 10:40 AM, observation revealed Dietary Staff (DS) CC prepared a pureed diet. DS CC placed four ounces of meatloaf in the Robot Coup (a food processor) and added an unmeasured amount of gravy. DS CC stated she started with approximately two tablespoons of gravy and added more if needed to get the correct consistency. DS CC blended the meat to a thin consistency, emptied the blended meatloaf into a metal pan and placed the pan into the warming well. Observation revealed DS CC then placed two ounces of green beans in the Immersion Stick blender (hand held-blender that mixed the ingredients to puree texture ) then added an unmeasured amount of bean juice and blended. DS CC emptied the pureed green beans into a metal pan and placed the pan into the warming well. Continued observation revealed DS CC placed the pureed meatloaf,…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$35,839 in federal fines across 2 penalties.

  • $9,149 — penalty dated 2025-06-02
  • $26,690 — penalty dated 2025-03-20

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.

Who owns this facility

Owner / managerTypeRoleShareSince
RIVERVIEW ESTATES INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/04/1976
WILLIAMS, SHILANDIndividualW-2 MANAGING EMPLOYEE; CORPORATE DIRECTORsince 06/04/2021
BUFFINGTON, SUSANIndividualCORPORATE DIRECTORsince 09/24/2019
HEDBERG, KENIndividualCORPORATE DIRECTORsince 09/29/2008
HULSE, MIKEIndividualCORPORATE DIRECTORsince 09/26/2021
KNIGHT, SHERRIIndividualCORPORATE DIRECTORsince 09/21/2023
MAYFIELD, ARTIndividualCORPORATE DIRECTORsince 09/22/2020

CMS files one row per role, so the 8 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner 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.

$3.2M
Net patient revenuemost recent cost report
-4.5%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 43%Medicare 8%Other / private 49%

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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

$291per resident / day
operating cost
$8,835per month
≈ monthly operating cost
$278per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). 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

Paying with Medicaid

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.

Typical monthly cost in Kansas
$8,669/mo
Nursing home (semi-private)
$9,064/mo
Nursing home (private)
$5,975/mo
Assisted living

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 175497. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-20, 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.

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