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Villa St Francis Catholic Care Center INC

16600 W. 126th St, Olathe, KS 66062 · Non profit - Corporation · 170 certified beds · (913) 829-5201 Medicare & Medicaid certified

Call the home — (913) 829-5201 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited May 2023Behavioral-health or dementia-care citation — no harm found (F0744)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (26% vs 45% nationally) — better care continuity
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score

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

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

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Urgent care / clinic
801 N Mur Len Rd Ste 105 · (913) 730-6487 · Call to confirm hours
Pharmacy
Hy-Vee1.1 mi
18101 W 119th St · (913) 393-4150 · Call to confirm hours
Grocery
12755 S Mur Len Rd · (913) 335-5717 · Call to confirm hours
Park
13045 S Mur-Len Rd · 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 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 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 rating5★
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 increased11.1%17.9%15.4%better
Long-stay residents who lose too much weight1.8%4.9%5.4%better
Long-stay residents with a catheter left in their bladder0.4%1.6%0.9%better
Long-stay residents with a urinary tract infection0.2%2.9%2.0%better
Long-stay residents with depressive symptoms1.4%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 injury1.4%4.3%3.3%better
Long-stay residents whose ability to walk worsened14.0%16.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication22.1%23.2%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.5%95.3%typical
Long-stay residents with pressure ulcers1.3%4.4%4.7%better
Long-stay residents with worsening bladder/bowel control14.5%22.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table10.1%18.1%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.9%1.4%better
Short-stay residents given the seasonal flu vaccine99.0%73.8%79.4%better
Short-stay residents rehospitalized after admission25.8%22.4%22.6%worse
Short-stay residents with an outpatient ER visit8.4%11.5%12.0%better
Long-stay hospitalizations per 1,000 resident days1.421.801.67better
Long-stay outpatient ER visits per 1,000 resident days0.372.131.80better

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.

47.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 29 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

47.0%U.S. median 51.5%
Got home and stayed home
9.5%U.S. median 10.7%
Went back to hospital
88.2%U.S. median 56.6%
Met the expected recovery
0.15U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.05hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 88.2% 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 68 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 0.15 therapist hours per resident per day in 2026Q1 — more than 13% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% 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 SNF47.0%CMS range 35.6–62.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.5%CMS range 6.4–14.210.7%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 discharge88.2%56.6%Oct 2024–Sep 2025CMS 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 discharge77.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge76.5%50.0%Oct 2024–Sep 2025CMS 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 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 setting100.0%100.0%Oct 2024–Sep 2025CMS 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS 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 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 worsened1.0%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 hospitalization5.9%CMS range 3.0–10.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.951.02Oct 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

0.73
RN hours/ resident / day
0.94
LPN hours/ resident / day
3.96
Aide hours/ resident / day
5.64
Total nurse hours/ resident / day
0.36
RN hoursweekends
25.9%
Total nursing turnover
25.0%
RN turnover

How full it usually is: this home is certified for 170 beds and averages 135.6 residents a day — about 80% occupied, or roughly 34 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 5.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.73 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.96 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 5.13 hrs/resident/day on weekends vs 5.84 on weekdays — 12% thinner on weekends. RN hours go from 0.88 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 26% is below 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

9
deficiencies at the latest standard inspection (2024-12-31)
8
at the previous standard inspection (2023-05-23)

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.

24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.

  • Potential for harm · Fcited before2024-12-31 · 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 identified a census of 136 residents. The facility identified 19 residents on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to ensure the blood pressure cuff, pulse monitor, and oxygen saturation equipment were sanitized after each resident's use and further failed to ensure all oxygen cannulas and nebulizer masks were stored in a sanitary manner. These deficient practices placed the residents at risk for infectious diseases. Findings included: - On 12/23/24 at 07:07 AM on the initial walk-through of the facility, Resident (R) 1's nebulizer mask laid directly on her dresser on a box next to her bed, and a rolled-up nasal cannula laid directly on the bedside table. On 12/24/24 at 07:18 AM, a tour through the laundry room revealed wet linens were left in the washer overnight. On 12/30/24 at 07:21 AM R1's nasal cannula laid over her oxygen canister next to her…

    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 · Ecited before2024-12-31 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    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 identified a census of 136 residents. The sample included 27 residents with four reviewed for pressure ulcers (localized injury to the skin or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear or friction). Based on interviews, observations, and record reviews, the facility failed to ensure Resident (R) 66's low air-loss mattress was set to the appropriate weight settings for pressure reduction. This deficient practice placed R66 at risk for complications related to skin breakdown and pressure ulcers. Findings included: - The Medical Diagnosis section within R66's Electronic Medical Records (EMR) noted diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), cognitive-communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), muscle weakness, dysphagia (difficulty swallowing), and type two diabetes mellitus (DM-when 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 · E2024-12-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure 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 had a census of 136 residents. The sample included 27 residents, with five residents reviewed for accidents and, or hazards. Based on observation, record review, and interview, the facility failed to secure areas containing hazardous materials to keep them out of reach of 28 cognitively impaired, independently mobile residents. This deficient practice placed the affected residents at risk for preventable injuries and accidents. Findings Included: - On 12/23/24 at 07:10 AM, a walkthrough of the facility was completed with the following observation: An inspection of the 100-unit (secured unit for severely cognitively impaired residents) revealed unlocked closets in the sitting area of the left-side dining room. Both closets contained purple disinfectant wipe containers and tile cleaner spray bottles. All products contained the warning, Keep out of reach of children, hazardous to humans, can cause eye irritation, and harmful if swallowed. An inspection of the facility's HM -hallway revealed a spray bottle of window cleaner in the kitchenette sink. The spray bottle…

    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 before2024-12-31 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 136 residents. The sample included 27 residents with three residents reviewed for dignity. Based on observation, record review, and interviews the facility failed to provide services in a dignified manner for Resident (R) 1 when staff stood over R1 while feeding her a pudding cup. This deficient practice placed R1 at risk for impaired dignity and decreased psychosocial well-being. Findings Included: - R1's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), muscle weakness, dysphagia (swallowing difficulty), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hyperlipidemia (condition of elevated blood lipid levels), major depressive disorder (major mood disorder that causes persistent feelings of sadness), aphasia (condition with…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-31 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each 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 identified a census of 136 residents. The sample included 27 residents. Three residents were sampled for reasonable accommodations of resident needs. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 16's call light was within her reach. This deficient practice left R16 vulnerable to unmet care needs due to the inability to call for staff assistance. Findings included: - R16's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), cardiac arrhythmia (a condition where the heart beats abnormally), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and insomnia…

    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 · D2024-12-31 · tag F0582 — isolated
    Give 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 136 residents. The sample included 27 residents with three residents reviewed for Beneficiary Notification. Based on record review and interview the facility failed to ensure a Centers for Medicare and Medicaid Services (CMS) form 10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form was provided to Resident (R) 117. This placed R117 at risk of uninformed treatment decisions and unexpected costs. Findings included: - A review of R117's Electronic Medical Record (EMR) documented that her Medicare Part A episode began on 10/01/24 and ended on 10/09/24. R117 remained in the facility for custodial care. R117 was provided the CMS form-10123 Notice of Medicare Non-Coverage (NOMNC) on 10/07/24. R117 was not issued the SNF ABN, form CMS-10055 as required. On 12/31/24 at 10:29 AM Social Services X stated she had been issuing the ABNs except for residents on managed care as their insurance directed the care and would send the documents. Social Services X stated to her understanding, the ABN was not made mandatory until…

    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 · D2024-12-31 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 136 residents. The sample included 27 residents with three residents reviewed for activities of daily living (ADL) care. Based on observation, record review, and interviews, the facility failed to ensure staff assisted Resident (R) 1 with grooming and failed to ensure R1's fingernails were cut short and kept clean. This deficient practice placed R1 at risk for impaired dignity, comfort, and further decline in ADL. Findings Included: - R1's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), muscle weakness, dysphagia (swallowing difficulty), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hyperlipidemia (condition of elevated blood lipid levels), major depressive disorder (major mood disorder that causes persistent feelings of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-31 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 136 residents. The sample included 27 residents with five residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 1's washcloth was applied to her hands. This deficient practice placed the resident at risk for discomfort and decreased range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). Findings Included: - R1's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), muscle weakness, dysphagia (swallowing difficulty), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hyperlipidemia (condition of elevated blood lipid levels), major depressive disorder (major mood disorder that causes persistent…

    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 · D2024-12-31 · 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 identified a census of 136 residents. The sample included 27 residents, with three residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure collaboration between the nursing home and hospice services to identify hospice-supplied services, supplies, medication, and equipment for Resident (R) 66. This deficient practice placed the resident at risk for delayed services and uncommunicated care needs. Findings included: - The Medical Diagnosis section within R66's Electronic Medical Records (EMR) noted diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), cognitive-communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), muscle weakness, dysphagia (difficulty swallowing), and type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R66's…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-05-23 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 118 residents. The sample included 25 residents. Based on observation, interview, and record review, the facility failed to provide food prepared in puree form (to chop or grind into a thick paste), from a standardized recipe for eight residents who received pureed meals which placed the residents at risk to not receive essential nutrients. Findings included: - On 05/18/23 at 11:10 AM, observation revealed Dietary Staff (DS) CC prepared the noon meal of which one of the menu items consisted of zucchini. DS CC placed the zucchini, with the liquid it had been prepared with, into the facility's blender. DS CC initiated the blender, added tap hot water and a commercial thickening agent. The facility's Pureed Seasoned Zucchini recipe instructed to place prepared, drained, vegetables in food processer and blend until a smooth consistency. The recipe instructed to add prepared hot broth if product needed thinning. The recipe specifically directed not to use water. On 05/23/23 at 08:09 AM, DS BB verified DS CC had not followed the zucchini pureed recipe, by…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · E2023-05-23 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 118 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility failed store, prepare, and serve food, in a sanitary condition for residents who received meals from the facility kitchen, which placed them at risk for food borne illness. Findings included: - On 05/18/23 at 11:00 AM, during observation of the kitchen, Dietary Staff (DS) BB reported the main kitchen dishwasher had not been working since 05/13/23. DS BB stated the repair required a part that had not been received. The kitchen was utilizing the three-compartment sink for washing cook and prep ware. The Hydrion Micro Essential sanitation test strip had an expiration date of September 15, 2021. DS BB reported she was not aware the testing strips had an expiration date. The facility's Sanitation policy, dated 11/01/22, documented manual washing and sanitizing will employ a three-step process for washing rinsing and sanitizing. Quaternary ammonium compound for time designated by the manufacturer. The facility failed to store, prepare, and serve food…

    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 · Dcited before2023-05-23 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 118 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility failed to promote care in a manner to maintain and enhance dignity and respect for one resident, Resident (R) 69, when another resident urinated on her while in the dining room. This placed R69 at risk for impaired dignity and psychosocial wellbeing. Findings included: - The Electronic Medical Record (EMR) for R69 documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS), documented R69 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and extensive assistance of one staff for eating and personal hygiene. R69's Care PLan dated 05/03/23…

    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 · Dcited before2023-05-23 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each 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 118 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility failed to provide a comfortable table height while dining for Resident (R) 65. This placed the resident at risk for discomfort and weight loss. Findings included: - The Electronic Medical Record (EMR) for R65 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), muscle weakness, pain, and need for assistance with personal cares. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R65 had severely impaired cognition and required extensive assistance of two staff for transfers, extensive assistance of one staff for bed mobility, ambulation, dressing, and personal hygiene. The assessment documented R65 required supervision and set-up assistance for eating. The Care Plan, 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-23 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    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 118 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility staff failed to report to administration a resident to resident incident for one sampled resident, Resident (R) 106, who urinated on another resident. This placed the residents at risk for unidentified abuse and/or ongoing mistreatment. Findings included: - The Electronic Medical Record (EMR) for R106 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The admission Minimum Data Set (MDS), dated [DATE], documented R106 had severely impaired cognition and required extensive assistance of one staff for bed mobility, toileting, dressing, personal hygiene, and required…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-23 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 118 residents. The sample included 25 residents with two residents reviewed for range of motion difficulties. Based on observation, interview, and record review, the facility failed to provide care and services to maintain range of motion for Resident (R) 61 who had contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) in both hands. This deficient practice placed R61 at risk for complications resulting from contracted hands. Findings included: - R61's Electronic Medical Record documented diagnoses of diabetes mellitus (group of diseases that result in too much sugar in the blood (high blood glucose), hypertension (high blood pressure), atrial fibrillation (irregular and often very rapid heart rhythm), encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), depression (mental health disorder characterized by persistently depressed mood or loss of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-23 · 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 118 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 104, who had incontinence, with toileting opportunities in an effort to avoid incontinence and related complications. This placed the resident at risk for skin breakdown and infections. Findings included: - The Electronic Medical Record (EMR) for R104 documented diagnoses of dementia without behavior disturbance (progressive mental disorder characterized by failing memory, confusion), difficulty walking, and muscle weakness. The Quarterly Minimum Data Set (MDS), dated [DATE] documented R104 had severely impaired cognition and required extensive assistance of two staff for transfers, toileting, and extensive assistance of one staff for bed mobility, ambulation, and personal hygiene. The MDS further documented R104 was frequently incontinent of bladder and had no toileting program. The Bowel and Bladder Care Plan, dated 04/25/23, initiated 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-23 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    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 118 residents. The sample included 25 residents, with five reviewed for behaviors. Based on observation, record review, and interview, the facility failed to provide the necessary dementia (progressive mental disorder characterized by failing memory, confusion) care and services for Resident (R) 106, who had behaviors of urinating in inappropriate places, grabbing items out of other resident's hands, and wandering. This placed the resident at risk for injury, unmet needs, and imapired quality of life. Findings included: - The Electronic Medical Record (EMR) for R106 documented diagnoses of dementia without behavioral disturbance, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The admission Minimum Data Set (MDS), dated [DATE], documented R106 had severely impaired cognition and required extensive assistance…

    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 · Ecited before2021-09-27 · tag F0880 — failed to prevent and control infections — pattern
    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 identified a census of 150 residents. The sample included 26 residents. Based on observations, record review and interviews the facility failed to ensure that facility staff properly utilized accepted standard universal precautions (infection prevention practices which include, but are not limited to hand hygiene and use of gloves) while performing percutaneous endoscopic gastrostomy (PEG- a tube placed in the stomach that allows a person to receive nutrition through the tube) care for resident (R)68; failed to ensure staff did proper hand hygiene during wound care for R128; failed to ensure that staff used a protective barrier and disinfect a glucometer (a machine used to obtain blood glucose levels) while obtaining R56 blood glucose level; and failed to ensure that a container used to distribute ice to residents glasses was covered and the scoop properly stored. Findings included: - On 09/23/21 at 08:37 AM Licensed Nurse (LN) J entered resident R68's room to do PEG tube care. She donned (put on) clean gloves without washing/sanitizing hands prior to putting on gloves.…

    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 · D2021-09-27 · 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 identified a census of 150 residents. The sample included 26 residents; one resident sampled for discharge review. Based on observations, record reviews, and interviews, the facility failed to provide a written notification of transfer to Resident (R) 49 or to her family/durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to). This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare services. Findings included: - R49 was admitted on [DATE], discharged to hospital on [DATE], and readmitted to facility 06/15/21. The Diagnoses tab of R49's Electronic Medical Record (EMR) documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance and dislocation of left hip. The Significant Change Minimum Data Set (MDS) dated [DATE], documented R49 had a Brief Interview for Mental…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-09-27 · 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 identified a census of 150 residents. The sample included 26 residents, with three residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure reducing measures were placed on Resident (R) 128's bilateral lower extremities to prevent pressure ulcers. This placed R128 at increased risk for pressure ulcer development. Findings included: - R128's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), pressure ulcer on buttocks, and diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Annual Minimum Data Set (MDS) dated [DATE] documented moderately impaired cognition from a staff interview. 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 · D2021-09-27 · 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 identified a census of 150 residents. The sample included 26 residents; one resident sampled for hemodialysis (procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) review. Based on observations, record reviews, and interviews, the facility failed to retain dialysis communication sheets and obtain or document vital signs and/or assessments after dialysis for Resident (R) 112. This deficient practice had the risk for adverse outcomes and unwarranted physical complications asscoaited with dialysis. Findings included: - The Diagnoses tab of R112's Electronic Medical Record (EMR) documented R112 had diagnoses of end stage renal disease (occurs when chronic kidney disease or the gradual loss of kidney function reaches an advanced state) and vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) without behavioral…

    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 · D2021-09-27 · 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 identified a census of 150 residents. The sample included 26 residents, with five residents sampled for medication review. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP- a pharmacist who works as a consultant to provide advice on the use of medications by elders) identified irregularities for two of five residents sampled for medication review: Resident (R) 20's blood pressure and/or pulse being monitored prior to administration of the beta blocker (a medication used to treat control heart rhythm, treat angina, and reduce blood pressure) carvedilol and R120's missed medication administrations with no documented physician notification of missed medications. Findings included: - The electronic medical record (EMR) for R20 documented diagnoses of atrial fibrillation (a rapid, irregular heartbeat), hypertension (HTN- an elevated blood pressure), congestive heart failure (CHF) - a condition with low heart output and the body becomes…

    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 · D2021-09-27 · 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 - R115's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented R115 required limited assistance of one staff member for activities of daily living (ADL's). The MDS documented R115 had received diuretic (medication to promote the formation and excretion of urine) medication and antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medication for seven days, anticoagulant (class of medications used to prevent the formation of blood clots) medication for six days and antibiotic (class of medication…

    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
  • No harm found · C2021-09-27 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 150 residents. Based on observations, record review, and interviews, the facility failed to ensure the results of the most recent health resurvey were available for residents, family, and legal representatives for review. Findings included: - On 09/23/21 at 03:20 PM a survey results binder was on a bookcase in the front sitting area behind the front entrance. The binder lacked the most recent health resurvey results and plan of correction from 2019. On 09/27/21 at 05:40 PM, Administrative Staff A stated she placed the most recent survey results and the plan of correction in the binder the moment she received them. The facility's Examination of Survey Results policy, last revised 04/07/21, directed survey reports and plans of correction are readily accessible to the resident and to the public. The policy directed a copy of the most recent survey report as well as the facility's plan for correcting identified problems was kept in a binder in the residents' day room. The facility failed to ensure the results of the most recent health resurvey were…

    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

“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

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
VILLA ST. FRANCIS REAL ESTATE HOLDINGS, INC.Organization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 01/03/2025
BENNING, JDIndividualCORPORATE DIRECTORsince 11/01/2022
BIBLER, MARYIndividualCORPORATE DIRECTORsince 01/01/2018
BREGANT, ROBERTIndividualCORPORATE DIRECTORsince 03/01/2022
MCKINZIE, MARKIndividualCORPORATE DIRECTORsince 01/01/2019
PARISE, BRETTIndividualCORPORATE DIRECTORsince 01/01/2018
PENNINGS, GARYIndividualCORPORATE DIRECTORsince 07/01/2009
SCOTT, JILLIANIndividualCORPORATE DIRECTORsince 01/01/2023
ANTHONY, NICOLEIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/03/2021
HEIDRICK, BRADLEYIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/07/2023
NORTHEAST KANSAS CATHOLIC HEALTHCARE SERVICES INC.OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2023
ALLIN, JILLIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/24/2024

CMS files one row per role, so the 19 rows in the source record cover these 12 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.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$14.2M
Net patient revenuemost recent cost report
-17.0%
Operating marginrevenue minus expenses
$1.0M
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 67%Medicare 4%Other / private 29%

This home reported $1.0M paid to related parties (affiliated landlords or management companies) in its most recent 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 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$383per resident / day
operating cost
$11,646per month
≈ monthly operating cost
$327per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in KS

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 175115. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-12-31, 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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