Advanced Health Care Of Overland Park
4700 Indian Creek Parkway, Overland Park, KS 66207 · For profit - Limited Liability company · 38 certified beds · (913) 890-8400 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (5/5)
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $13,397 in federal fines (most recent 2023-12-13)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 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
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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 |
| 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 improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 1.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 85.3% | 73.8% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 21.5% | 22.4% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 7.5% | 11.5% | 12.0% | better |
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.
72.9% 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 527 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 48.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 287 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 1.22 therapist hours per resident per day in 2026Q1 — more than 98% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 72.9%CMS range 68.4–77.0 | 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 | 10.7%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 | 48.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 47.4% | 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 | 41.1% | 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 | 82.8% | 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 | 97.7% | 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 | 27.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.5% | 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 | 1.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 4.5%CMS range 2.6–6.3 | 7.1% | Oct 2023–Sep 2024 | better than U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.99 | 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 38 beds and averages 38.0 residents a day — about 100% occupied, or roughly 0 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.92 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.89 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 4.30 hrs/resident/day on weekends vs 5.18 on weekdays — 17% thinner on weekends. RN hours go from 1.78 to 1.07 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 37% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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.
23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.
- Immediate jeopardy · Jcited before2023-12-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 38 residents. The sample included three residents reviewed for accidents. Based on record review, interview, and observations, the facility failed to identify hazards and implement adequate supervision and care to ensure safe smoking for Resident (R) 1. R1 admitted to the facility on [DATE] at approximately 01:00 PM. R1 was alert and oriented to person place time and situation and received oxygen via nasal cannula at six liters per minute (LPM). At 05:15 PM on 12/08/23, Certified Nurse Aide (CNA) M took R1 outside for a cigarette break while R1 wore his oxygen. CNA M locked R1's wheelchair brakes and went back inside. Between 05:26 PM and 05:29 PM, R1 lit his cigarette. Around 05:34 PM R1's nasal cannula ignited. R1 removed the nasal cannula, shook it, and attempted to put out the flame. At approximately 05:35 PM, Licensed Nurse (LN) H approached the facility for her scheduled shift. LN H observed R1 swinging the nasal cannula tubing around and trying to put out the fire. LN H…
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 · D2026-02-26 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 identified a census of 38 residents. The sample included six residents with three residents reviewed for abuse/neglect. Based on record review and interviews, the facility failed to submit completed investigations within the required five working-day timeframe following reported allegations to the State Agency (SA) for Residents (R) 1 and R2. Findings included:- R1 admitted to the facility on [DATE] and discharged to home on [DATE]. R2 admitted to the facility on [DATE] and transferred to the hospital on [DATE]. Review of the facility's notifications to the State Agency (SA) revealed the following: The facility reported intake number 2715968 to the SA on 01/13/26. The intake documented on 01/12/26 at 03:00 PM. The facility received an email from R1's representative that on 01/12/26 between the hours of 02:00 AM and 03:00 AM, R1 put on her call light to request urgent medical assistance, and staff failed to respond in a timely manner. As a result, R1 remained unattended while in acute physical…
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 · D2026-02-26 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 38 residents. The sample included six residents with three residents reviewed for abuse/neglect. Based on record review and interviews, the facility failed to conduct a complete investigation to rule out abuse and neglect after receiving allegations from representatives for Resident (R) 1 and R2. Findings included:- R1 admitted to the facility on [DATE] and discharged to home on [DATE]. R2 admitted to the facility on [DATE] and transferred to the hospital on [DATE]. Review of the facility's notifications to the State Agency (SA) revealed the following: The facility reported intake number 2715968 to the SA on 01/13/26. The intake documented on 01/12/26 at 03:00 PM. The facility received an email from R1's representative that on 01/12/26 between the hours of 02:00 AM and 03:00 AM, R1 put on her call light to request urgent medical assistance, and staff failed to respond in a timely manner. As a result, R1 remained unattended while in acute physical distress and R1 told 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.
- Potential for harm · Fcited before2024-09-25 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 35 residents with one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to food storage. This deficient practice placed the residents who received food from the facility kitchen at risk related to food-borne illnesses and food safety concerns. Findings included: - On 09/23/24 at 07:27 AM, an observation in the kitchen's dry food storage room revealed one container of pistachios. The container was not labeled and lacked a date. On 09/23/24 at 07:31 AM, an observation in the kitchen's dry food storage room revealed one opened box of puree pasta mix. The box had an opened bag inside that contained the pasta mix. The box and bag lacked a date. On 09/23/24 at 07:33 AM, an observation in the kitchen's dry food storage room revealed one opened box of honey wheat flavoring. The box had an opened bag inside that contained the honey wheat flavoring. The box and bag lacked a date. On 09/23/24 at 07:35 AM, an observation in the kitchen's dry food storage room revealed one opened…
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 · E2024-09-25 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 35 residents. The sample included 12 residents. Based on interview and record review, the facility failed to develop and implement a policy that prohibited and prevented the facility from employing or engaging staff with criminal backgrounds when the facility failed to conduct a background check as required for one employee and the facility policy allowed for 10 days of employment prior to the check. The deficient practice placed all residents at risk for abuse, neglect, misappropriation, or mistreatment. Findings included: - Employee review of Licensed Nurse (LN) H revealed a hire date of 07/03/19. The facility was unable to provide evidence a criminal background check had been completed by the facility for LN H upon request. On 09/25/24 at 11:55 AM Administrative Staff A stated the facility did not have a criminal background check on file for LN H. Administrative Staff A stated he was unable to find LN H's background check after searching through the older files in storage. Administrative Staff A stated LN H was originally hired for home health…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-09-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 35 residents. The sample included 12 residents with three reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure a safe environment free from hazardous chemicals and materials for eight cognitively impaired independently mobile residents. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings Included: - On 09/23/24 at 07:30 AM a walkthrough of the facility's Two Hall revealed an unlocked wound treatment cart. The cart contained multiple bottles of medicated diclofenac (used to treat pain) and nystatin (used to treat fungal infections) ointments with the warning of Keep medication out of reach of children. The cart also contained three purple containers of Sani-Cloth bleach wipes with the Keep out of reach from children warning label. CNA M stated the cart belonged to the nurse but secured it. On 09/24/24 at 07:10 AM an inspection of the facility's One Hall revealed the wound cart was unsecured. The cart contained five bottles of diclofenac, a box of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-25 · 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 35 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) 75 had her call light to communicate her needs or call for help. This deficient practice placed the resident at risk for unmet care needs. Findings Including: - The Medical Diagnosis section within R75's Electronic Medical Records (EMR) included diagnoses of fracture of her sacrum (bone break of the large triangular bone/area between the two hip bones), fracture of the lumber vertebra (spinal fracture of the lower back), insomnia (difficulty sleeping), and history of repeated falls. R75's admission Minimum Data Set (MDS) completed 09/20/24 noted a Brief Interview for Mental Status (BIMS) score of 11 indicating mild cognitive impairment. The MDS indicated she required supervision with bed mobility, toileting, transfers, personal hygiene, dressing, and personal hygiene. The MDS noted no falls since her admission. R75's Functional Abilities Care Area Assessment…
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 · D2024-09-25 · 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 35 residents. The sample included 12 residents with three residents reviewed for beneficiary notices review. Based on record review, and interviews, the facility failed to provide Resident (R)82 with a Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) CMS -10095 Form upon discharge from Medicare A services. This deficient practice placed the resident at risk for uninformed decisions and inability to exercise her rights. Findings Included: - R82's Discharge Minimum Data Set (MDS) completed 08/30/24 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated she was discharged home and was not anticipated to return to the facility. A review of R82's Beneficiary Protection Notification Review completed on 09/24/24 indicated she started Medicare Part A skilled services on 07/08/24. The form designated her last covered day (LCD) as 08/29/24. The form indicated the facility initiated her discharge from skilled with benefit days remaining and she left the facility upon…
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 before2024-09-25 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 35 residents. The sample included 12 residents with three reviewed for activities of daily living (ADLs). Based on observation, record review, and interviews, the facility failed to provide consistent bathing opportunities for Residents (R)18. This deficient practice placed R16 at risk for decreased psychosocial well-being and other complications. Findings Including: - The Medical Diagnosis section within R18's Electronic Medical Records (EMR) included diagnoses of malignant neoplasm of the pancreas (pancreatic cancer), nausea with vomiting, and gastroesophageal reflux disease (GERD-backflow of stomach contents to the esophagus). R18's admission Minimum Data Set (MDS) completed 09/08/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated she required supervision and/or touch assistance from staff for bathing, toileting, dressing, personal hygiene, bed mobility, and transfers. The MDS indicated she admitted with no…
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 · D2024-09-25 · 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 35 residents. The sample included 12 residents with three reviewed for bowel and bladder management. Based on observation, record review, and interviews, the facility failed to ensure appropriate Foley catheter (a tube inserted into the bladder to drain urine into a collection bag) care for Resident (R)16 when staff failed to maintain the urine collection bag below R16's bladder to encourage dependent drainage. This deficient practice placed R16 at risk for catheter-related complications including urinary tract infections (UTI). Findings Including: - The Medical Diagnosis section within R16's Electronic Medical Records (EMR) included diagnoses of chronic kidney disease, spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), hemiplegia and hemiparesis (weakness and paralysis on one side of the body), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R16's admission Minimum Data Set (MDS) completed 08/23/24 noted a Brief…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-25 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 35 residents. The sample included 12 residents with two reviewed for nutritive diets. Based on observation, record review, and interviews, the facility failed to ensure meals were served at a palatable, safe, and appetizing temperature for Residents (R)75 and R76. This deficient practice placed the residents at risk for impaired nutrition and decreased quality of life. Findings included: - On 09/23/24 at 07:45 AM R75 stated the facility would often serve the food cold in the mornings. She stated staff were available to warm up the food in the microwaves if asked. On 09/23/24 at 08:00 AM R76 stated breakfast often was served cold by the time it reached her room. On 09/23/24 at 12:51 PM, R18 stated the meals were often cold by the time the food was delivered to the rooms. She stated she was told by staff she would have to eat in the cafeteria if she wanted her meals to be served hot. (R18 was sent out to an acute care facility at 04:30 PM on 09/23/24) On 09/24/24 at 08:20 AM R75 received her breakfast tray. A temperature test was completed on 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.
Show the remaining 12 citations
- Potential for harm · Dcited before2024-09-25 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 35 residents. Based on record reviews, observations, and interviews, the facility failed to follow sanitary infection control standards related to maintaining biliary drains (catheter drain inserted in the liver) and Foley catheters (a tube inserted into the bladder to drain urine into a collection bag). These deficient practices placed the residents at risk for infectious diseases. Findings Included: - On 9/23/24 at 08:15 AM Resident(R)75 slept in her bed. R75's bed was in the lowest position and her urinary catheter collection bag rested flat on the floor to the right of her bed. On 09/23/24 at 10:18 AM R18 slept in her bed. R18's bed was in the lowest position. R18's tubing for her biliary drain ran over her covers to the right side of her bed. Her drainage collection bag rested on the floor to the right of her bed. On 09/25/24 at 01:51 PM Certified Nurse's Aide (CNA) M stated the medical drains and catheter bags should never touch the floor. He stated they should be positioned below the level of the bladder to ensure proper drainage and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-02-28 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 30 residents. The facility had one main kitchen and one dining area. The facility failed to ensure that staff members properly tested the dishwashing sanitization chemicals and recording the dish machine temperatures. The facility also failed to ensure the ice machine lid was closed in the nourishment area was closed This deficient practice placed residents at risk for contamination and food borne illness. Findings included: - The initial tour of the facility on 02/23/23 at 07:04 AM the Dietary Staff DD reported the facility had changed chemical sanitization companies in the past two weeks and chemical strips provided by the new company had not been testing within the facility set guidelines. Dietary Staff DD stated the new distributor had been notified. On 02/23/23 at 07:05AM the door of the ice machine in the nourishment was left open with the ice exposed. Review of the Dish Machine Temperature Log from 02/01/23 to 02/27/23 revealed 17 undocumented dish machine water temperature opportunities out of 81 opportunities. Review of the parts per…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-02-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 56 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to secure chemicals in a safe, locked area, and out of reach of the five cognitively impaired independently mobile residents. This placed the affected residents at risk for accidents. Findings Included: - On 02/23/23 at 07:05 AM an initial walkthrough of the facility revealed opened Micro-Kill germicidal cylindrical containers of disinfectant wipes were in the hallway, unsecured, outside of Residents (R)7, R23, R88, R90, and R142's rooms. The disinfectant wipes were also noted outside of unoccupied rooms 104, 105, 108, 114, and 134. The walkthrough revealed 12 total containers of chemical wipes left unsecured. The label of the wipes contained the warning, Keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. On 02/28/23 at 01:49 PM Certified Nurses Aid (CNA) M stated all chemical products should securely locked up away from resident access. On 02/28/23 at 01:49 PM Licensed Nurse (LN) G stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-28 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 30 residents. The sample included 12 residents with two residents reviewed for care plan revisions related to accidents. Based on observation, record review, and interviews, the facility failed to revise Residents (R)15 and R33's care plans to reflect interventions implemented for recent falls. This deficient practice placed both residents at risk for uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R15's Electronic Medical Records (EMR) included diagnoses of multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord), fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue and severe sleep disturbance), muscle spasms, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and muscle weakness. A review of R15's admission Minimum Data Set (MDS) dated 01/12/23 noted a Brief Interview for Mental Status (BIMS) score of six indicating severe cognitive impairment. The MDS indicated she required extensive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-02-28 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 30 residents. The sample included 12 residents with two reviewed for activities of daily living (ADL). Based on observations, record review, and interviews, the facility failed to provide consistent bathing opportunities and the level of assistance required for Resident (R)15. This deficient practice placed R15 at risk for impaired skin integrity, discomfort, and decreased psychosocial well-being. Findings Included: -The Medical Diagnosis section within R15's Electronic Medical Records (EMR) included diagnoses of multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord), fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue and severe sleep disturbance), muscle spasms, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and muscle weakness. A review of R15's admission Minimum Data Set (MDS) dated 01/12/23 noted a Brief Interview for Mental Status (BIMS) score of six indicating severe cognitive impairment. The MDS indicated she required…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-09-01 · tag F0756 — failed to review each resident's drug regimen — patternEnsure 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 37 residents. The sample included 13 residents with five residents sampled for unnecessary medication review. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported to the facility irregularities (bowel monitoring was not being documented daily for Resident (R)23, weights were not obtained as ordered for R81 and R82, blood sugars were not obtained as ordered for R78). This deficient practice placed the residents at increased risk for complications related to unnecessary medications and adverse effects. Findings included: -The electronic medical record (EMR) for R23 documented diagnoses of fractures (broken bone) of lumbar spine, hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (disrupted blood flow to the brain), constipation (difficulty passing stools), and aphasia (condition with disordered or absent…
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 · E2021-09-01 · tag F0757 — failed to avoid unnecessary drugs — patternEnsure 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 13 residents with five residents sampled for unnecessary medication review. Based on observation, record review, and interview, the facility failed to ensure that bowel monitoring was being documented daily and bowel medications administered as ordered for Resident (R)23 and R78, weights were obtained as ordered for R81, and R82, and blood sugars were obtained as ordered for R78. This deficient practice placed the residents at increased risk for complications related to unnecessary medications and adverse effects. Findings included: - The electronic medical record (EMR) for R23 documented diagnoses of fractures (broken bone) of lumbar spine, hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (disrupted blood flow to the brain), constipation (difficulty passing stools), and aphasia (condition with disordered or absent language function), chronic low back pain.…
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 · E2021-09-01 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 37 residents, two medication carts, one treatment cart, and one medication storage room. Based on observations, record reviews, and interviews, the facility failed to discard expired medications and influenza (a common viral infection that can be deadly, especially in high-risk groups) vaccinations; failed to properly store and date Tubersol (tuberculin purified protein derivative [PPD- sterile solution of a purified protein derivative used in the diagnosis of tuberculosis]); failed to properly store and date insulin (medication used to treat a chronic condition that affected the way the body processed blood sugar); failed to properly store and date medicated eye drops; and failed to properly store and date a medicated inhaler (device used for administering a medication that was breathed in to relieve asthma [disorder of narrowed airways that caused wheezing and shortness of breath] or other lung disorders). This deficient practice had the risk for unwarranted physical complications and ineffective treatment for affected residents. Findings…
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 · D2021-09-01 · 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 13 residents; one resident sampled for hospitalization. Based on record review and interviews, the facility failed to provide a written notification of transfer, as soon as was practicable, to Resident (R) 178 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: - R178 was admitted to facility on 07/12/21, transferred to hospital 07/22/21, returned to facility 07/23/21, discharged to hospital 07/23/21, readmitted to facility 07/28/21, then discharged to hospital 08/06/21. R178's Electronic Medical Record (EMR) documented diagnoses of fracture of unspecified part of right clavicle (bone that connects the breastplate to the shoulder), cellulitis (skin infection caused by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-09-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 37 residents. The sample included 13 residents with three residents sampled for falls. Based on observations, record reviews, and interviews, the facility failed to investigate causative factors and ensure interventions were followed for the prevention of falls for Resident (R) 8. This deficient practice placed R8 at increased risk for further falls, possible injuries from falls, and unwarranted physical complications. Findings included: - R8's Electronic Medical Record (EMR) documented a diagnosis of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting right dominant side. The admission Minimum Data Set (MDS) dated [DATE], documented R8 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R8 required…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-09-01 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 38 residents. The sample included 13 residents with five residents reviewed for medications. Based on record review, observations and interviews, the facility failed to ensure Resident (R)18 was free from unnecessary psychotropic (affecting mood or thinking) medications when the facility failed to ensure R18's as needed (PRN) lorazepam ( psychotropic antianxiety medication) had the required stop date of 14 days. This placed R18 at risk for unnecessary medications and side effects associated with lorazepam use. Findings included: - R18's electronic medical record (EMR) recorded diagnoses of generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), falls and altered mental status. The admission Minimum Data Set (MDS) dated [DATE] recorded R18 had a Brief interview for mental Status (BIMS) score of eight which indicated severely impaired cognition. The MDS recorded R18 had no behaviors. The MDS recorded R18 did not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-09-01 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 37 residents, the sample included 13 residents. Based on observations, record reviews, and interviews, the facility failed to perform hand hygiene after doffing (removing) gloves or before donning (putting on) gloves during dressing changes. This deficient practice had the risk to spread illness and infection to all residents and prolonged wound healing for Resident (R) 179 and 78. Findings included: - On 09/01/21 at 09:30 AM, Administrative Nurse E performed hand hygiene in R179's sink. She then donned gloves and elevated R179's left arm on a pillow in preparation for the peripherally inserted central catheter (PICC- a form of intravenous access that can be used for a prolonged period of time) dressing change. She doffed gloves then donned new gloves, no hand hygiene performed between. She removed the previous dressing. On 09/01/21 at 09:34 AM, Administrative Nurse E doffed gloves and performed hand hygiene. She opened the sterile (meaning free from microorganisms) dressing change tray on R179's bedside table. She opened her additional packaged…
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
$13,397 in federal fines across 1 penalty.
- $13,397 — penalty dated 2023-12-13
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to ADVANCED HEALTH CARE — 26 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 4.8 | +0.2 vs chain |
| Health inspection | 3 of 5 | 4.2 | -1.2 vs chain |
| Staffing | 5 of 5 | 4.1 | +0.9 vs chain |
| Quality measures | 5 of 5 | 4.8 | +0.2 vs chain |
The other 25 homes this chain runs (chain average 4.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| NEW AHC HOLDINGS, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 01/01/2021 |
| THE GAIL MILLER GST TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 72% | since 01/01/2024 |
| THE BRYAN MILLER UTAH DYNASTY TRUST DATED APRIL 22, 2014 | Organization | INDIRECT OWNERSHIP INTEREST | — | since 01/01/2024 |
| THE G&H MILLER UTAH TRUST DATED FEBRUARY 26, 2019 | Organization | INDIRECT OWNERSHIP INTEREST | — | since 01/01/2024 |
| OXNAM, NATHAN | Individual | CORPORATE OFFICER | — | since 01/01/2024 |
| PIPPITT, BRYAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2023 |
| LHMSH LLC | Organization | ADP OF THE SNF | — | since 01/01/2024 |
| HURA, PAUL | Individual | ADP OF THE SNF | — | since 05/01/2025 |
CMS files one row per role, so the 10 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.
5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $995K paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in KS
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Kansas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175542. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-09-25, 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.