The Plaza Health Services At Santa Marta
13875 W 115th Terrace, Olathe, KS 66062 · Non profit - Corporation · 50 certified beds · (913) 906-0990 Medicare only — no Medicaid
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)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 1 actual-harm citation
- a high number of inspection citations overall (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
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) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 17.5% | 17.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.1% | 4.9% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.6% | 1.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 3.2% | 2.9% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 2.0% | 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 | 3.1% | 4.3% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 10.3% | 16.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 24.5% | 23.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.8% | 4.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 26.8% | 22.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.8% | 18.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.8% | 1.9% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 86.9% | 73.8% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 18.6% | 22.4% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 9.6% | 11.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.92 | 1.80 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.32 | 2.13 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
64.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 284 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 67.6% 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 111 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 0.56 therapist hours per resident per day in 2026Q1 — more than 86% 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
| 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 | 64.0%CMS range 58.1–69.6 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.3%CMS range 8.0–12.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 67.6% | 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 | 55.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 46.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.4% | 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 | 3.5% | 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 | 6.6%CMS range 4.1–10.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.94 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 50 beds and averages 42.4 residents a day — about 85% occupied, or roughly 8 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 5.31 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.74 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.94 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 4.92 hrs/resident/day on weekends vs 5.46 on weekdays — 10% thinner on weekends. RN hours go from 0.87 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
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 fewer than at the previous inspection — improving. 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.
20 citations, most serious first. The 11 most serious are shown; the remaining 9 are one tap away and print in full.
- Actual harm · Gcited before2024-07-31 · 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
The facility identified a census of 37 residents. The sample included 12 residents with three reviewed for accidents. Based on record review, interviews, and observations, the facility failed to ensure adequate supervision resulting in preventable falls for Resident (R) 29. This deficient practice resulted in a pelvic fracture for R29 and created the risk for pain and impaired mobility. The facility additionally failed to safely secure hazardous materials, cleaning chemicals, and supplemental oxygen cylinders from eight cognitively impaired ambulatory mobile residents. This placed the residents at risk for preventable accidents and injuries. Findings Including: - The Medical Diagnosis section within R29's Electronic Medical Records (EMR) included diagnoses of a right femur (large leg bone) fracture (broken bone), left femur fracture upon admission, muscle weakness, cognitive-communication deficit, repeated falls, and dementia (a progressive mental disorder characterized by failing memory, confusion). R29's Quarterly Minimum Data Set (MDS) completed 04/21/24 noted a Brief Interview…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-14 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure interdisciplinary staff assessed Resident (R) 8 for the ability to safely self-administer medication before the staff gave R8 her Flonase nasal spray, to keep in her room, per R8's request. Findings include:- R8's Electronic Medical Record (EMR) documented diagnoses of pulmonary fibrosis (a progressive disease where the lung tissue thickens, making it increasingly difficult for oxygen to pass into the bloodstream), chronic obstructive pulmonary disease (COPD- causes obstructed airflow from the lungs, making it difficult to breathe), interstitial pulmonary disease (a disorder that causes progressive scarring of lung tissue), chronic hypoxia (inadequate supply of oxygen), anxiety (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), vertigo, and transient ischemic attack (TIA- brief blockage of blood flow to the brain, causing stroke-like symptoms). R8's Annual Minimum Data Set (MDS) dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-14 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to notify the Office of the Long-term Care Ombudsman (LTCO) for the discharge of Resident (R) 46. Findings included:- R46's Electronic Medical Record (EMR) revealed diagnoses of: Traumatic subarachnoid hemorrhage (bleeding into the area between the brain and the protective tissue covering it, resulting from a head injury), right upper humerus fracture, cardiomegaly (an enlarged heart), atrial fibrillation (A-fib - a rapid, irregular heartbeat), muscle weakness, and a cognitive communication deficit. R46's Discharge with Return Not Anticipated Minimum Data Set (MDS) dated [DATE] documented a BIMS score of 10, indicating moderate cognitive impairment, without a diagnosis of dementia. On 03/18/26 at 03:16 PM, a progress note documented a conversation with R46's daughter, discussing provisions for R46, as family wanted the resident to move back to her Independent Living (IL) apartment on 03/19/26. The interdisciplinary team (IDT) was notified,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to identify and implement resident-centered interventions and monitor effectiveness of interventions to prevent falls for Resident (R) 27, who was at high risk for falls. Findings included: - R27's Electronic Health Record (EHR) documented diagnoses of anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), major depressive disorder (major mood disorder that causes persistent feelings of sadness), weakness, abnormalities of gait and mobility, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), repeated falls (two or more falls within a specific time frame, typically a year or six months), and dementia (a progressive mental disorder characterized by failing memory and confusion). R27's Annual Minimum Data Set (MDS), dated 05/20/25, documented a Brief Interview for Mental Status (BIMS) score of 14, which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-14 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary dialysis post assessment, care, and services for Resident (R) 23 when staff failed to provide post-dialysis assessments. Findings included:- R23's Electronic Health Record (EHR) documented diagnoses that included Infection and inflammatory reaction due to peritoneal dialysis (procedure performed to remove toxins, drugs, or other wastes in the blood normally excreted by the kidney) catheter (a flexible tube inserted through a narrow opening into a body cavity), spontaneous bacterial peritonitis (a life threatening, severe inflammation of the peritoneum) (the thin tissue that lines the inside of your abdomen and covers your organs), intestinal obstruction, intestinal adhesions, end stage renal disease (ESRD-a terminal disease of the kidneys), diabetes mellitus (DM-when the body cannot use glucose when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypothyroidism (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 · F2024-07-31 · tag F0585 — failed to handle grievances — widespreadHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 37 residents. Based on observations, record reviews, and interviews, the facility failed to provide a method for residents to submit grievances anonymously. This deficient practice had the risk of loss of resident rights, unresolved grievances, and a loss of dignity for the residents in the facility. Findings included: - On 07/29/24 at 07:05 AM, entry into the skilled facility involved going through locked double doors from the main entrance area that Assisted Living shared. The double doors required a code to exit to the main entrance area from the skilled facility side. During the initial tour of the skilled facility on 07/29/24 at 07:30 AM, observation revealed there was no submission box or method for filing anonymous grievances. On 07/31/24 at 09:49 AM, Social Services X stated if a resident wanted to file a grievance anonymously, the facility encouraged them to talk to her. She stated if the resident wanted to remain anonymous, she left their name off of the grievance form and then distributed the grievance to the appropriate department 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 · F2024-07-31 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 37 residents. The sample included 12 residents. Based on observations, record review, and interviews, the facility failed to follow infection prevention standards related to disinfecting shared equipment and oxygen tubing storage and failed to place the appropriate isolation signage outside of Resident (R) 192's room after he tested positive for COVID-19 (an acute respiratory illness in humans caused by coronavirus, capable of producing severe symptoms and in some cases death). The facility further failed to assess, identify risks, and create a plan to address the risk for Legionella disease (Legionella is a bacterium that can cause pneumonia in vulnerable populations) or other opportunistic waterborne pathogens. This deficient practice placed the residents at risk for infectious diseases. Findings included: - R192's EMR documented an order with a start date of 07/22/24 for isolation for 10 days starting 07/21/24 for a positive COVID-19 infection. On 07/29/24 at 07:14 AM, R14's oxygen concentrator had her oxygen tubing placed in the handle instead…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-31 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 37 residents. The sample included 12 residents with one reviewed for accommodation of needs. Based on record review, interviews, and observations, the facility failed to ensure Resident (R) 23 had a call light within reach to communicate his need for staff assistance. This deficient practice placed the residents at risk for preventable falls and injuries. Findings Including: - The Medical Diagnosis section within R23's Electronic Medical Records (EMR) included diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), overactive bladder, cognitive communication deficit, and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R23's Significant Change Minimum Data Set (MDS) completed 07/11/24 noted a Brief Interview for Mental Status (BIMS) score of zero indicating severe cognitive impairment. The MDS indicated he had functional limitations in both his…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-31 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 37 residents with 12 residents included in the sample. Based on interview and record review the facility failed to issue the CMS (Center for Medicare/Medicaid Services) Notification of Medicare Non-Coverage (NOMNC- the form used to notify Medicare A participants of their rights to appeal and the last covered date of service) Form 10123 which contained the required information for Resident (R) 193. This failure placed the resident at risk for decreased autonomy and impaired right to appeal. Findings included: - A review of R193's Electronic Medical Record (EMR) documented that the Medicare Part A episode began on 01/13/24 and ended on 02/01/24. R193 was discharged home from the facility. The facility failed to provide evidence that the NOMNC was given to R193. A Plan of Care Progress Note dated 01/22/24 documented that a care plan meeting was held with the resident, interdisciplinary team, and the resident's two daughters with one son present via speaker phone. A date was discussed for return to home. The resident reported being anxious to go home…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-31 · tag F0623 — isolatedProvide 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 identified a census of 37 residents. The sample included 12 residents. Two residents were reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide written notification of transfer to Resident (R) 12 and R29 or their representatives. The facility further failed to notify the State Long Term Care Ombudsman of transfers/discharges for R29. This deficient practice had the risk of miscommunication between the facility and resident/representative and possible missed opportunities for healthcare services for R12 and R29 and placed R29 at risk for impaired rights. Findings included: - R12 admitted to the facility on [DATE], discharged to hospital on [DATE], and readmitted to the facility on [DATE]. R12's Electronic Medical Record (EMR) documented diagnoses of a fracture of the lower end of the right femur (thigh bone), weakness, pain in the right hip, and generalized muscle weakness. The admission Minimum Data Set (MDS), dated 06/20/24, documented R12…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-31 · tag F0625 — isolatedNotify 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 identified a census of 37 residents. The sample included 12 residents. Two residents were reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide a bed hold policy notice to Resident (R) 12 and R29 or their representatives when they transferred to the hospital. This deficient practice had the risk of impaired ability to return to the facility and to the previous room for R12 and R29. Findings included: - R12 admitted to the facility on [DATE], discharged to hospital on [DATE], and readmitted to the facility on [DATE]. R12's Electronic Medical Record (EMR) documented diagnoses of a fracture of the lower end of the right femur (thigh bone), weakness, pain in the right hip, and generalized muscle weakness. The admission Minimum Data Set (MDS), dated 06/20/24, documented R12 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA),…
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 9 citations
- Potential for harm · D2024-07-31 · tag F0661 — isolatedEnsure 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 identified a census of 37 residents. The sample included 12 residents. Two residents were reviewed for discharge. Based on record review and interviews, the facility failed to document a recapitulation of stay for Resident (R) 38 and R39. This deficient practice placed R38 and R39 at risk for miscommunication of services received during their stay in the facility and of their post-discharge care needs. Findings included: - R38 admitted to the facility on [DATE] and discharged on 07/05/24. R38's Electronic Medical Record (EMR) documented diagnoses of essential hypertension (high blood pressure), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and generalized muscle weakness. The admission Minimum Data Set (MDS), dated 06/11/24, documented R38 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R38 planned to discharge to the community and active discharge planning occurred in the facility. 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 · D2024-07-31 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 37 residents. The sample included 12 residents with one reviewed for bowel and bladder management. Based on observation, record review, and interviews, the facility failed to implement timed toileting interventions as indicated in the assessment and failed to assess ongoing patterns of incontinence to establish bowel and bladder patterns to maintain or improve Resident (R)21's incontinence. This deficient practice placed R21 at risk for complications related to incontinence. Findings Including: - The Medical Diagnosis section within R21's Electronic Medical Records (EMR) included diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), hypertension (high blood pressure), dementia (a progressive mental disorder characterized by failing memory, confusion), and benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections). R21's Significant Change Minimum Data Set (MDS)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-31 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 37 residents. The sample included 12 residents with three residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure that Resident (R)14's bed rails were removed as indicated per her side rail assessment. This placed R14 at risk for impaired safety related to the risks associated with the use of side rails. Findings Including: - The Medical Diagnosis section within R14's Electronic Medical Records (EMR) included diagnoses of dysphagia (difficulty swallowing), encephalopathy (inflammatory condition of the brain), muscle weakness, overactive bladder, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and difficulty walking. R14's Quarterly Minimum Data Set (MDS) completed 05/11/24 noted a Brief Interview for Mental Status (BIMS) score of 13 indicating mild cognitive impairment. The MDS indicated she required substantial to maximal assistance for bed mobility, transfers, bathing, grooming, dressing, personal hygiene, and mobility. The MDS indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-31 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 37 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observations, record review, and interviews, the facility failed to notify the physician of elevated blood pressure as directed and failed to administer antihypertensive (medication used to treat high blood pressure) medications as needed for Resident (R) 26. This deficient practice placed R26 at risk for unnecessary medications and physical complications related to uncontrolled blood pressure. Findings included: - R26 was admitted to the facility on [DATE]. R26's Electronic Medical Record (EMR) documented diagnoses of essential hypertension (high blood pressure) and permanent atrial fibrillation (a-fib- rapid, irregular heartbeat). The admission Minimum Data Set (MDS) dated 04/08/24, documented R26 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R26 received antidepressant (medication used to treat depression [abnormal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-31 · tag F0849 — isolatedArrange 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 37 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 a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R)24. This placed R24 at risk for inappropriate end-of-life care. Findings included: - R24's Electronic Medical Record (EMR) revealed diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), dementia (a progressive mental disorder characterized by failing memory and confusion), and diabetes mellitus (DM-when the body cannot use glucose, not enough…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-31 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 37 residents. The sample included 12 residents with five residents reviewed for 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 a signed declination for the Prevnar 20 (pneumococcal vaccination used for the prevention of pneumococcal disease caused by 20 serotypes of Streptococcus pneumoniae) pneumococcal vaccination for Resident (R) 23. This deficient practice placed R23 at risk of acquiring, spreading, and experiencing complications from pneumococcal disease. Findings included: - R23's clinical record documented he received Prevnar 13 (pneumococcal vaccination used for the prevention of pneumococcal disease caused by 13 serotypes of Streptococcus pneumoniae [bacteria that causes pneumonia]) on 02/25/14 and Pneumovax 23 (pneumococcal vaccination used for the prevention of pneumococcal disease caused by 23 serotypes of Streptococcus pneumoniae) on 03/22/17. R23's clinical record…
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 · E2022-10-24 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 37 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to provide an accurate reconciliation of controlled drugs at the end of daily work shifts. This placed residents at risk for misappropriation of medications by staff. Findings included: - On 10/24/22 at 09:12 AM, observation of the 1700 front-hall medication cart revealed staff had not signed the Eight Hour Verification of Controlled Substance Count Sheet at shift change 33 times from 10/01/22 to 10/24/22. On 10/24/22 at 09:12 AM, observation of the 1700 back-hall medication cart revealed staff had not signed the Eight Hour Verification of Controlled Substance Count Sheet at shift change 19 times from 10/01/22 to 10/24/22. On 10/18/22 at 10:04 AM, Licensed Nurse (LN) G stated two nurses should count the narcotic medications every shift and sign the Eight Hour Verification of Controlled Substance Count Sheet to verify an accurate narcotic medication count. On 10/24/22 at 09:22 AM, Licensed Nurse (LN) H stated two nurses should count 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.
- No harm found · C2026-05-14 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to display accurate and identifiable posted nurse staffing information. Findings included:- On 05/12/26 at 07:25 AM, observation revealed a daily staffing sheet hanging on the wall near the administrative offices of the facility. Review of the Daily Nursing Staffing Information sheet on 05/12/26 revealed the sheet lacked the correct posting date. The posted sheet on 05/12/26 was dated 05/08/26. On 05/12/26 at 08:54 AM the posted daily nursing staffing information sheet was posted with the date 05/12/26.On 05/14/26 at 09:42 AM, Administrative Nurse A reported they oversee the facility staffing coordinators. Administrative Nurse A further reported the position is split between 2 people. A charge nurse would be responsible for posting the daily nursing staffing sheet if a staffing coordinator is not available for that day. It is my expectation that the daily nursing staffing sheet is changed & updated daily. This is the reason we now have 2 staffing for complete coverage of this function.On 05/14/2026 at 10:21 AM,…
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 · C2024-07-31 · tag F0620 — widespreadNot require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 37 residents. Based on record review and interviews, the facility failed to establish and implement an admissions agreement that protected the residents' right to personal property by not waiving the facility's liability. Findings included: - The facility's Nursing admission and Care Agreement revealed under section D Standard admission Waiver on page four, section four, that residents and their families realized the facility could not guarantee the safety of personal items and the facility was not responsible for loss, theft, or damage to resident's personal property. The facility maintained a safe in which personal articles of a small size or limited dollar value were stored. It was agreed by all parties that money, jewelry, documents, furs, and other personal articles of significant monetary value that were brought into the facility by the resident, responsible party, or other guests were a violation of D.4. of the agreement and were not the responsibility of the facility. On 07/31/24 at 12:30 PM, Administrative Staff A stated the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| SURMACZEWICZ, CHESTER | Individual | CONTRACTED MANAGING EMPLOYEE; CORPORATE DIRECTOR | since 06/03/2009 |
| ANDREWS, MARK | Individual | W-2 MANAGING EMPLOYEE | since 05/25/2004 |
| LANAHAN, MICHAEL | Individual | W-2 MANAGING EMPLOYEE | since 05/25/2004 |
| STEINHOFF, PAUL | Individual | W-2 MANAGING EMPLOYEE | since 05/25/2004 |
| AHLVERS, CAROL | Individual | CORPORATE DIRECTOR | since 01/01/2019 |
| BARON, REGAN | Individual | CORPORATE DIRECTOR | since 01/01/2020 |
| BLECHA, DEBRA | Individual | CORPORATE DIRECTOR | since 01/01/2018 |
| BOLIG, JEFF | Individual | CORPORATE DIRECTOR | since 03/01/2021 |
| ELDRIDGE, KAREN | Individual | CORPORATE DIRECTOR | since 01/01/2022 |
| ERKMANN, CATHERINE | Individual | CORPORATE DIRECTOR | since 01/01/2017 |
| FOGEL, LARRY | Individual | CORPORATE DIRECTOR | since 01/01/2022 |
| FRIEL, MICHELLE | Individual | CORPORATE DIRECTOR | since 01/01/2021 |
| GRAMS, JON | Individual | CORPORATE DIRECTOR | since 01/01/2021 |
| HAASE, BRIAN | Individual | CORPORATE DIRECTOR | since 01/24/2018 |
| HAWKEN, MIKE | Individual | CORPORATE DIRECTOR | since 01/01/2022 |
| JACOBSON, DAN | Individual | CORPORATE DIRECTOR | since 01/01/2020 |
| MCKEAN, DANIEL | Individual | CORPORATE DIRECTOR | since 01/01/2019 |
| MOORMAN, DOUG | Individual | CORPORATE DIRECTOR | since 01/01/2017 |
| O'TOOLE, PEGGY | Individual | CORPORATE DIRECTOR | since 01/01/2022 |
| PAYNE, MICHAEL | Individual | CORPORATE DIRECTOR | since 01/01/2018 |
| SCHMIDT, ANDREW | Individual | CORPORATE DIRECTOR | since 01/01/2019 |
| SIEVE, GREG | Individual | CORPORATE DIRECTOR | since 01/01/2021 |
| SKOCH, MICHAEL | Individual | CORPORATE DIRECTOR | since 01/01/2022 |
| THOMAS, LESLIE | Individual | CORPORATE DIRECTOR | since 01/01/2022 |
| URBAN, TIM | Individual | CORPORATE DIRECTOR | since 01/01/2017 |
| WAY, RADD | Individual | CORPORATE DIRECTOR | since 01/01/2019 |
| WHITAKER, MARY | Individual | CORPORATE DIRECTOR | since 01/01/2022 |
| WILSON, WILLIAM | Individual | CORPORATE DIRECTOR | since 01/01/2022 |
| ZACCARDI, JANE | Individual | CORPORATE DIRECTOR | since 01/01/2017 |
| GREYSTONE MANAGEMENT SERVICES COMPANY LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 04/21/2008 |
CMS files one row per role, so the 31 rows in the source record cover these 30 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.
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.
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 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
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
CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Kansas Medicaid page for homes that do.
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 175503. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-14, 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.