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Brookdale Overland Park

12000 Lamar Avenue, Overland Park, KS 66209 · For profit - Corporation · 94 certified beds · (913) 663-2888 Medicare & Medicaid certified

Call the home — (913) 663-2888 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0605) — cited Jan 2026Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — 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 (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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

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

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
5701 W. 119 · (913) 661-9980 · Call to confirm hours
Pharmacy
6407 W 119th, St G5 · (913) 307-1730 · Call to confirm hours
Grocery
6621 W. 119th St. · (913) 663-2951 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
6731 W 119th St · (913) 685-3883

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 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 4 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 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 increased8.6%17.9%15.4%better
Long-stay residents who lose too much weight2.2%4.9%5.4%better
Long-stay residents with a catheter left in their bladder1.3%1.6%0.9%worse
Long-stay residents with a urinary tract infection2.3%2.9%2.0%worse
Long-stay residents with depressive symptoms0.0%6.5%6.5%check this — see note marked star below the table
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 injury3.7%4.3%3.3%worse
Long-stay residents on antianxiety or hypnotic medication28.0%23.2%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.5%95.3%typical
Long-stay residents with pressure ulcers2.1%4.4%4.7%better
Long-stay residents with worsening bladder/bowel control31.8%22.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table13.3%18.1%17.1%better
Short-stay residents who newly got an antipsychotic medication0.7%1.9%1.4%better
Short-stay residents given the seasonal flu vaccine92.8%73.8%79.4%better
Short-stay residents rehospitalized after admission27.1%22.4%22.6%worse
Short-stay residents with an outpatient ER visit13.0%11.5%12.0%typical

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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

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

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

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

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

69.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 669 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

69.0%U.S. median 51.5%
Got home and stayed home
9.6%U.S. median 10.7%
Went back to hospital
74.8%U.S. median 56.6%
Met the expected recovery
0.68U.S. median 0.31
Therapy hours / resident / day
0.35hours / resident / day
Physical therapy
0.26hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 74.8% 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 274 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 0.68 therapist hours per resident per day in 2026Q1 — more than 91% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF69.0%CMS range 64.7–72.151.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.6%CMS range 7.7–11.810.7%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 discharge74.8%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 discharge66.4%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 discharge66.4%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 identified94.0%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 setting95.2%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 discharge98.4%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 stay1.1%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 worsened1.4%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 hospitalization6.2%CMS range 4.3–8.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.941.02Oct 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

1.45
RN hours/ resident / day
0.84
LPN hours/ resident / day
1.91
Aide hours/ resident / day
4.20
Total nurse hours/ resident / day
1.01
RN hoursweekends
53.3%
Total nursing turnover
46.7%
RN turnover

How full it usually is: this home is certified for 94 beds and averages 74.9 residents a day — about 80% occupied, or roughly 19 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.20 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.45 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.91 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.62 hrs/resident/day on weekends vs 4.43 on weekdays — 18% thinner on weekends. RN hours go from 1.63 to 1.01 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 53% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

3
deficiencies at the latest standard inspection (2026-01-22)
13
at the previous standard inspection (2024-03-06)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

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.

23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.

  • Potential for harm · Dcited before2026-04-14 · 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 Based on observations, interviews, and record review, the facility failed to ensure Resident (R) 1 was treated with dignity and respect when Certified Nurses Aide (CNA) M snapped her fingers at R1 in order to get his attention so he would stop acting out.Findings included:- R1's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dysphagia (swallowing difficulty), muscle weakness, delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue), lack of coordination, dementia (progressive mental disorder characterized by failing memory, confusion), and Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness).R1's Admission/ Five Day Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. R1 required partial to moderate…

    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 · E2026-01-22 · 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 77 residents. The sample included 18 residents, with two reviewed for accidents. Based on observation, record review, and interview, the facility failed to secure a blanket warming equipment and pressurized supplemental oxygen tanks in a safe, locked area and out of reach of the eight cognitively impaired, independently mobile residents. Findings Included:- On 01/19/26 at 07:04 AM, a walkthrough of the facility revealed an unsecured storage closet next to the nurse's station on the 400 hallway. An inspection of the unsecured closet revealed 25 (full size) and six (small) fully pressurized cylindrical oxygen containers in the oxygen racks. An inspection of the unsecured closet also revealed an Enthermics EC2060 blanket warming unit. The unit was warm to touch and set to 200 degrees Fahrenheit. On 01/19/26 at 07:10 AM, Licensed Nurse (LN) G verified the room was unsecured and stated staff were expected to ensure the door was fully closed before exiting the room. She stated the room was to always remain locked. On 01/22/26 at 11:20 AM, Administrative Nurse…

    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 · D2026-01-22 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    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 77 residents. The sample included 18 residents, with six residents reviewed for unnecessary medication. Based on record review and interviews, the facility failed to ensure Resident (R) 70's as-needed Lorazepam, antianxiety (a class of medications that calm and relax people) medication had a 14-day stop date, or a physician's rationale for extended use.Findings included:- R70's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (elevated blood pressure), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), aphagia (loss of the ability to swallow), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), and encounter for palliative care.The Significant Change Data Set (MDS) dated [DATE] documented a Brief Interview…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-22 · 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

    The facility identified a census of 77 residents. The sample included 18 residents, with one resident reviewed for hospice services. Based on interviews, observation, and record review, the facility failed to provide a description of the medication, services, and equipment provided to Resident (R) 51 by hospice.Findings included:- R51's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), Lewy body dementia (a type of progressive brain disorder that leads to a decline in thinking, reasoning, and independent function), and major depressive disorder (major mood disorder that causes persistent feelings of sadness).The Significant Change Minimum Data Set (MDS) dated 09/10/25 documented a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognition, and no staff interview was completed. The MDS documented R51 received hospice services during the observation period. R51's Cognitive Loss/Dementia Care Area Assessment (CAA)…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-03-06 · 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 78 residents. The sample included 23 residents. Based on record review, observations, and interviews, the facility failed to ensure adequate infection control standards were followed during Resident (R)189's enteral meal (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew, or swallow food) administration and storage of R290's oxygen therapy equipment. The facility additionally failed to ensure clean linen storage. This deficient practice placed the residents at risk for infectious diseases. Findings Included: - On 03/04/24 at 07:17 AM an inspection of the 400 Hall clean linen storage closet revealed a dusty, visibly soiled vacuum cleaner stored in the closet next to uncovered clean linen. On 03/04/24 at 07:52 AM, an inspection of R290's room revealed his continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask placed face down on the nightstand next to his bed. No clean storage container was present in his…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-06 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 78 residents. The sample included 23 residents with 10 reviewed for pneumococcal (type of bacterial infection) immunizations. Based on record review and interviews, the facility failed to ensure the resident and/or resident's representatives were informed and educated on the pneumococcal vaccination options and provided the current Vaccination Information Statements (VIS) for Residents (R) 30, R48, R50, R66, and R76. This deficient practice placed the residents at risk for complications related to infectious diseases. Findings Included: - On 03/06/24 at 08:00 AM a review of pneumococcal immunizations was completed for R13, R20, R30, R32, R33, R48, R50, R59, R66, and R76. R30's (severely cognitively impaired resident) Electronic Medical Record (EMR) indicated she was admitted to the facility on [DATE]. The EMR noted she received the Pneumovax 23 (PPSV23-pneumococcal vaccination) before her admission in 2018. An electronically filed Informed Consent for Pneumococcal Vaccine was…

    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 · Dcited before2024-03-06 · 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 identified a census of 78 residents. The sample included 23 residents with five residents reviewed for activities of daily living (ADLs). Based on observations, record review, and interviews, the facility failed to promote care for Resident (R) 30, who was dependent on staff assistance for all ADLs, in a manner that preserved R30's dignity. These deficient practices placed the resident at risk for impaired psychosocial well-being and an undignified living environment. Findings included: - On 03/04/24 at 11:06 AM R30's room was located across from an open communal dining room. R30's door was open. R30 lay in her bed; she wore an incontinence brief and was uncovered from the waist down. R30 was visible from the hallway and part of the dining room while she lay in her bed, with her brief and legs exposed. Staff walked past her room in the hallway while some residents sat in the dining room. On 03/05/24 at 03:25 PM, R30's door was open. R30 lay in bed and slid her bare feet across her mattress. R30 wore only an incontinence brief, and she was uncovered. R30's exposed body…

    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 · D2024-03-06 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    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 78 residents. The sample included 23 residents. Based on observation, record review, and interviews, the facility failed to identify a significant change in the physical condition and complete a comprehensive Significant Change Minimum Data Set (MDS) for Resident (R) 33 with the addition of hospice services. This deficient practice placed R33 at risk for unidentified care needs. Findings included: - R33's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of atrial fibrillation (rapid, irregular heartbeat), cerebrovascular accident (CVA-stroke- the 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), dementia (a progressive mental disorder characterized by failing memory, confusion), and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-06 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 78 residents. The sample included 23 residents. Based on observations, record reviews, and interviews, the facility failed to ensure accurate assessment and documentation on the Minimum Data Set (MDS) related to Resident (R)87's discharge location. This deficient practice had the risk of miscommunication related to R87's continued care needs. Findings Included: - The Medical Diagnosis section within R87's Electronic Medical Records (EMR) included diagnoses of atrial fibrillation (A-fib: rapid, irregular heartbeat), hypertension (high blood pressure), muscle weakness, history of sepsis (a life-threatening systemic reaction that develops due to infections which cause inflammation throughout the entire body), syncope (fainting or passing out), and repeated falls. R87's admission MDS completed 12/13/23 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated he was dependent on staff for bed mobility, toileting, bathing, dressing, and hygiene. The MDS indicated he used a wheelchair for mobility 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-06 · 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

    The facility identified a census of 78 residents. The sample included 23 residents with five residents reviewed for activities of daily living (ADLs). Based on observations, record review, and interviews, the facility failed to provide ADL assistance to Resident (R) 30, who was dependent on staff assistance for all ADLs. These deficient practices placed the residents at risk of decreased psycho-social well-being and impaired ADL. Findings included: - R30's Electronic Medical Record (EMR) documented diagnoses of restless leg syndrome (a condition that causes a very strong urge to move the legs), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS) dated 02/05/24, documented R30 had a Brief Interview for Mental Status (BIMS) score of 00 which suggested severely impaired cognition. The MDS documented R30 used a wheelchair and required substantial/maximal assistance for bathing, and upper body dressing. 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
Show the remaining 13 citations
  • Potential for harm · D2024-03-06 · 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 78 residents. The sample included 23 residents with four 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 two residents, Resident (R) 13 and R28 received pressure-reducing interventions for pressure ulcers. This placed R13 and R28 at increased risk for pressure ulcer development. Findings included: - R13's Electronic Medical Record (EMR) documented diagnoses of venous insufficiency (poor circulation), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) with diabetic neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased…

    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 · D2024-03-06 · 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 identified a census of 78 residents. The sample included 23 residents with three reviewed for bowel and bladder management. Based on observations, record review, and interviews, the facility failed to ensure appropriate Foley catheter care (a tube inserted into the bladder to drain urine into a collection bag) for Resident (R)340 when staff failed to maintain the urine collection bag below R340's bladder to encourage dependent drainage. This deficient practice placed R340 at risk for complications related to urinary tract infections (UTI). Findings Included: - The Medical Diagnosis section within R340's Electronic Medical Records (EMR) included diagnoses of hypertension (high blood pressure), history of falling, recent hip fracture (broken bone), retention of urine, and cervical spondylosis (age-related breakdown of bones in her hip) R340's EMR indicated she was admitted on [DATE] and a Minimum Data Set (MDS) was not completed for review. R340's Care Plan initiated 02/29/24 indicated she had an…

    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 · D2024-03-06 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 78 residents. The sample included 23 residents with one resident sampled for intravenous (IV-administered directly into the bloodstream via a vein) therapy. Based on observation, record review, and interview, the facility failed to assess and document the location, appearance, and patency (the quality of being open and unobstructed) each shift for Resident (R) 191's IV access site. This placed R191 at risk of infection and complications related to IV therapy. Findings included: - The electronic medical record (EMR) for R191 documented diagnoses of infection and inflammation reaction due to internal joint prosthesis (a device that is placed inside a person's body during a procedure to permanently replace joint), and methicillin-susceptible staphylococcus aureus infection (MSSA- a bacterial infection that develops when bacteria enter the body through a cut or wound on the skin). The admission Minimum Data Set (MDS) for R191 had not been completed yet due to her admission date 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 before2024-03-06 · 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 78 residents. The sample included 23 residents with seven residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities regarding the lack of dosing instructions for Voltaren (topical pain reliever medication) gel for Resident (R) 33. This deficient practice had the risk of unnecessary medication use and physical complications for R33. Findings included: - R33's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of atrial fibrillation (rapid, irregular heartbeat), cerebrovascular accident (CVA-stroke- the 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), dementia (a progressive mental disorder characterized by failing memory, confusion), and Parkinson's disease (a slowly progressive neurologic disorder characterized 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-06 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 78 residents. The sample included 23 residents with five residents sampled for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure a dosage was indicated for the use of Voltaren (a topical gel used for the treatment of pain) for Resident (R) 73 and R33. This deficient practice placed R73 and R33 at risk for unnecessary medication administration and possible adverse side effects. Findings included: - The electronic medical record (EMR) for R73 documented diagnosis of effusion (accumulation of fluid) of the left knee, pain in the left knee, and fracture of the left tibia (the inner and typically larger of the two bones between the knee and the ankle) The admission Minimum Data Set (MDS) dated 02/04/24 documented R73 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R73 had a functional limitation in the range of motion on one side of both upper and lower extremities. R73 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-06 · tag F0775 — isolated
    Keep complete, dated laboratory records in the resident's record.
    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 78 residents. The sample included 23 residents. Based on observation, record review, and interviews, the facility failed to ensure that physician-ordered laboratory test results for Resident (R) 28 were included in R28's clinical record. This deficient practice could result in unnecessary tests and delayed treatment. Findings included: - R28's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R28 received diuretic medication (medication to promote the formation and excretion of urine) during the observation period. The Quarterly MDS dated 12/29/23 documented a BIMS score of 12 which indicated…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-06 · 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 78 residents. The sample included 23 residents with two residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure a communication process was implemented, which included how the communication would be documented between the facility and the hospice provider, and a failed to provide a description of the services, medication, and equipment provided to Resident (R) 33 by hospice. This deficient practice created a risk for missed or delayed services and impaired physical, and psychosocial care for R33. Findings included: - R33's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of atrial fibrillation (rapid, irregular heartbeat), cerebrovascular accident (CVA-stroke- the 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), dementia (a progressive mental disorder characterized by failing memory,…

    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 · Ecited before2022-09-08 · tag F0756 — failed to review each resident's drug regimen — pattern
    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 80 residents. The sample included 18 residents with seven reviewed for medication regimen review. Based of observations, record review, and interviews, the facility failed to ensure that the Consulting Pharmacist (CP) identified Resident (R)27's blood pressure medication given outside of physician ordered parameters. The CP also did not identify and report an inappropriate diagnoses for R11, R31, and R64's antipsychotic medications (class of medications used to treat psychosis and other mental emotional conditions). This placed the residents at risk for unnecessary medication and adverse side effects. Findings Included: - The Medical Diagnosis section within R27's Electronic Medical Records (EMR) included diagnoses of type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hypotension (low blood pressure), quadriplegia (paralysis of the arms, legs and trunk of the body below the level of an associated…

    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 · Ecited before2022-09-08 · 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 80 residents. Based of observations, record review, and interviews, the facility failed to promote adequate infection control practices related to wound care for Residents (R)72, R33, R73, and R180. This deficient practice placed the residents at risk for complications related to wound infections and increased the risk for cross contamination. Findings Included: - On 09/07/22 at 10:20AM while performing wound care to R180, Licensed Nurse (LN) G gathered supplies and placed a Chux pad (absorbent disposable barrier) under R180. LN G washed her hands and donned gloves. LN G opened the supplies onto the Chux pad. LN G then removed the old bandages and threw them into the trash can. LN G then cleaned the wound area with the same soiled gloves. LN G removed her gloves and threw them in the trash. LN G donned a new pair of gloves without completing hand hygiene and applied new bandages. LN G gathered the used supplies and repositioned R180 in a comfortable position. LN G removed her gloves and completed hand hygiene. On 09/07/22 at 10:30AM R33 received…

    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 · Dcited before2022-09-08 · 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

    The facility identified a census of 80 residents. The sample included 18 residents with three reviewed for activities of daily living (ADL's). Based on observations, record review, and interviews, the facility failed to provide R72's scheduled bathing per her preferred bathing schedule. This deficient practice placed R72 at risk for poor hygiene and related complications. Findings Included: - The Medical Diagnosis section within R72's Electronic Medical Records (EMR) included diagnoses of spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), hypertension (high blood pressure), muscle weakness, pressure ulcer right of the heal (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), unsteadiness on feet, atherosclerosis (narrowing and hardening of the blood vessels), and morbid obesity (severely overweight). R72's admission Minimum Data Set (MDS) dated 08/25/22 noted a Brief Interview for Mental Status (BIMS) score 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 · D2022-09-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 80 residents. The sample included 16 residents with one resident reviewed for respiratory services. Based on observation, record review, and interviews, the facility failed to store oxygen tubing and nasal cannula (device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) in a sanitary manner for Resident (R) 131. This deficient practice placed R31 at increased risk to develop a respiratory infection. Findings included: - R131's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness) and dementia in other diseases classified elsewhere with behaviors disturbances (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS) was in progress. R131 admitted [DATE]. R131's Care Area Assessment (CAA) was in progress. R131's Care Plan lacked…

    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 before2022-09-08 · 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

    The facility identified a census of 80 residents. The sample included 18 residents with seven reviewed for unnecessary medications. Based of observations, record review, and interviews, the facility failed to ensure that the physician's ordered medication parameters were followed for Resident (R)27 and R39's blood pressure medication. This deficient practice placed the resident's at risk for unnecessary medication administration and adverse side effects. Findings Included: - The Medical Diagnosis section within R27's Electronic Medical Records (EMR) included diagnoses of type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hypotension (low blood pressure), quadriplegia (paralysis of the arms, legs and trunk of the body below the level of an associated injury to the spinal cord), 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), neuralgia (severe pain due to damaged nerves that causes severe…

    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 · D2022-09-08 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 80 residents. The sample included 18 residents with five residents sampled for unnecessary medication review. Based on observation, record review and interview, the facility failed to ensure that Resident (R)11, R64, and R131 had an appropriate diagnosis for their antipsychotic (a class of medications used to treat psychosis and other mental emotional conditions) medication Seroquel (medication used to treat certain mental/mood conditions [such as schizophrenia a psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought]). This placed R11, R64, and R31 at risk for unnecessary antipsychotic medication administration and related side effects. Findings included: - The electronic medical record (EMR) for R11 documented diagnoses of: dementia with behavioral disturbance (progressive mental disorder characterized by failing memory, confusion and behaviors including agitation, verbal and 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.

    Pharmacy Service 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.

Part of a chain

This home belongs to BROOKDALE SENIOR LIVING — 12 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 →

RatingThis homeChain avg
Overall 4 of 53.5+0.5 vs chain
Health inspection 4 of 52.8+1.2 vs chain
Staffing 4 of 54.1≈ chain avg
Quality measures 4 of 54.3-0.3 vs chain
The other 11 homes this chain runs (chain average 3.5★, 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 / managerTypeRoleSince
AMERICAN RETIREMENT CORPORATIONOrganizationDIRECT OWNERSHIP INTERESTsince 08/01/2009
BROOKDALE SENIOR LIVING INCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 02/27/2025
KUSSOW, DAWNIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 04/30/2025
WHITE, CHADWICKIndividualINDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 03/09/2018
ALLY BANKOrganization5% OR GREATER SECURITY INTERESTsince 02/09/2024
KENT, CINDYIndividualMANAGING CONTROL - GOVERNING BODYsince 11/20/2020
STENGLE, NIKOLASIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 11/08/2025
DAVISON, ANDRALIEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 07/22/2025
ELLIS, KIMBERLYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2009
LA MARRE, KEVINIndividualOPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 01/22/2017
MAHER, MARYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 07/22/2025
MUNOZ, ANNAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/05/2024
ALLY FINANCIAL INCOrganizationADP OF THE SNFsince 09/08/2025
BKD OVERLAND PARK LLCOrganizationADP OF THE SNFsince 02/27/2025
BROOKDALE SENIOR LIVING COMMUNITIES INCOrganizationADP OF THE SNFsince 02/27/2025
BSLCI-DEVELOPMNET HOLDINGS LLCOrganizationADP OF THE SNFsince 02/27/2025
FEBC-ALT HOLDINGS INCOrganizationADP OF THE SNFsince 02/27/2025
FEBC-ALT INVESTORS LLCOrganizationADP OF THE SNFsince 02/27/2025
IB FINANCE HOLDING COMPANY LLCOrganizationADP OF THE SNFsince 09/08/2025
LBMC PCOrganizationADP OF THE SNFsince 01/01/2024
WALTERS FINANCIAL SERVICES INCOrganizationADP OF THE SNFsince 07/22/2025
ASHER, JORDANIndividualADP OF THE SNFsince 02/24/2020
BACON, KENNETHIndividualADP OF THE SNFsince 07/22/2025
BELISLE, JEFFREYIndividualADP OF THE SNFsince 07/22/2025
CARY, WILLIAMIndividualADP OF THE SNFsince 07/22/2025
DRAYTON, CLAUDIAIndividualADP OF THE SNFsince 06/18/2024
FENNEBRESQUE, KIM BIndividualADP OF THE SNFsince 07/22/2025
FIORAVANTI, MARKIndividualADP OF THE SNFsince 04/13/2025
FREED, VICTORIAIndividualADP OF THE SNFsince 10/29/2019
GARCIA, STEPHANIEIndividualADP OF THE SNFsince 09/09/2025
HAUSMAN, JOSHUAIndividualADP OF THE SNFsince 04/24/2025
MACE, ELIZABETHIndividualADP OF THE SNFsince 06/18/2024
SHARPLESS, BRIANIndividualADP OF THE SNFsince 07/22/2025
WARREN, DENISEIndividualADP OF THE SNFsince 10/04/2018
WIELANSKY, LEEIndividualADP OF THE SNFsince 04/23/2015

CMS files one row per role, so the 42 rows in the source record cover these 35 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.

12 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.

$22.0M
Net patient revenuemost recent cost report
-9.4%
Operating marginrevenue minus expenses
$205K
Related-party expense1% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 19%Other / private 81%

This home reported $205K 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

$410per resident / day
operating cost
$12,465per month
≈ monthly operating cost
$375per 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 175517. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-22, 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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