Colonial Village
12500 W 137th St, Overland Park, KS 66221 · For profit - Corporation · 40 certified beds · (913) 730-3700 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- 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
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- nursing-staff turnover (63%) runs well above the national median (45%)
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 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 held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 15.2% | 17.9% | 15.4% | typical |
| Long-stay residents who lose too much weight | 6.2% | 4.9% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.9% | 2.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 6.5% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.7% | 4.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 16.1% | 16.2% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 9.9% | 23.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.2% | 4.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 22.9% | 22.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.6% | 18.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.4% | 1.9% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 92.7% | 73.8% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 25.6% | 22.4% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 3.9% | 11.5% | 12.0% | better |
* 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.
48.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 100 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 56.1% 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 41 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 0.30 therapist hours per resident per day in 2026Q1 — more than 47% 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
| 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 | 48.8%CMS range 38.7–58.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.4%CMS range 6.6–14.9 | 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 | 56.1% | 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 | 43.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 39.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 97.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.1% | 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 | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.6%CMS range 3.8–11.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.82 | 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 40 beds and averages 34.8 residents a day — about 87% occupied, or roughly 5 beds typically open. It runs fairly full. 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 4.43 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.00 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.83 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 4.02 hrs/resident/day on weekends vs 4.59 on weekdays — 12% thinner on weekends. RN hours go from 1.08 to 0.81 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 63% is well above 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
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · G2024-10-31 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 36 residents. The sample included 13 residents with one reviewed for nutrition. Based on observation, record review, and interviews, the facility failed to provide nutritional interventions to prevent Resident (R)25's identified and continued slow weight loss. As a result of the deficient practice, R25 had a significant unplanned weight loss of 13.06 percent (%) within three months. This also placed R25 at risk for malnourishment related complications. Findings Included: - The Medical Diagnosis section within R25's Electronic Medical Records (EMR) included diagnoses of insomnia (difficulty sleeping), progressive supranuclear palsy (PSP- a rare neurodegenerative disorder characterized by progressive deterioration of the brain cells), dementia (a progressive mental disorder characterized by failing memory and confusion), and dysphagia (difficulty swallowing). R25's admission Minimum Data Set (MDS) completed 05/15/24 noted a Brief Interview for Mental Status (BIMS) score of six…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-10-31 · tag F0730 — widespreadObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 36 residents. The sample included 13 residents. Five Certified Nurse Aides (CNAs) were reviewed for yearly performance evaluations and in-service training. Based on record review and interview, the facility failed to ensure one of the five reviewed CNA staff had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's performance evaluation and in-service records revealed the following: CNA O, hired on 06/21/23, had no yearly performance evaluations. On 10/31/24 at 12:15 PM Administrative Nurse D stated the facility did not have the required yearly performance evaluations for CNA O. She stated yearly performance evaluations were completed annually for all CNA staff. The facility's Staff Requirement policy 06/2010 indicated performance reviews will be conducted on each employee at least annually to identify to identify employee strengths and goals. The policy noted the evaluation will be utilized to determine the training needs of the employee. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-10-31 · 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 36 residents with one kitchen and two dining rooms with kitchenettes. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to the storage of food. This deficient practice placed the residents at risk related to food-borne illnesses. Findings Included: - On 10/29/24 an inspection of the facility's kitchen was completed. An inspection of the walk-in refrigerator unit revealed an open but undated half-gallon carton of milk and a carton of heavy whipping cream. An inspection of the back hall kitchenette revealed an unlabeled plate of spinach and beef sandwich and an undated bag with dessert pastries. An inspection of the main dining kitchenette drink station revealed an open and undated bottle of whipping cream. The refrigerator contained an eight-fluid-ounce container of Arginaid (wound care supplemental drink) with an expiration date of June 2024. On 10/31/24 at 09:30 AM Dietary Staff BB stated all opened food products should be labeled and dated. She stated staff should not be placing…
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 before2024-10-31 · tag F0880 — failed to prevent and control infections — patternProvide 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 36 residents. Based on observation, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to hand hygiene and disinfecting shared equipment between each resident. These deficient practices placed the residents at risk for complications related to infectious diseases. Findings included: - Observation on 10/29/24 at 09:15 AM Resident (R)36 sat in her wheelchair. Certified Nurse Aide (CNA) M and CNA N donned their gowns and gloves. CNA M placed the mechanical sit-to-stand lift in front of R36. CNA M then placed R36's catheter bag onto the side of the knee brace on the mechanical lift. Using the lift, staff transferred R36 onto the toilet. CNA N removed R36's pants and incontinent brief. CNA N provided peri-care to R36's rectal area. CNA N removed her gloves, and without performing hand hygiene, donned another pair of gloves. CNA M provided peri-care around R36's catheter. CNA M wiped several swipes with one cleansing wipe around the catheter tubing and peri-area. Wearing the same soiled…
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 · D2024-10-31 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 36 residents. The sample included 13 residents with one resident reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide written notification of transfer to Resident (R)32 and/or their representative, with a written notice specifying the location and reason for R32's facility-initiated transfer. This deficient practice placed R32 at risk for miscommunication between the facility and resident/representative and possible missed opportunities for healthcare services. Findings included: - The Medical Diagnosis section within R32's Electronic Medical Records (EMR) included diagnoses of dysphagia (difficulty swallowing), cognitive-communication disorder, dementia (a progressive mental disorder characterized by failing memory and confusion), and acute kidney failure. R32's Discharge Minimum Data Set (MDS) completed 10/04/24 indicated she was discharged with an anticipated return to the facility. The MDS indicated she 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.
- Potential for harm · D2024-10-31 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 36 residents. The sample included 13 residents with one resident reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide a copy of the bed hold policy to Resident (R)32 and/or their representative, when R32 was transferred to the hospital. This deficient practice placed R32 at risk for impaired right to return to the facility to the same room. Findings included: - The Medical Diagnosis section within R32's Electronic Medical Records (EMR) included diagnoses of dysphagia (difficulty swallowing), cognitive-communication disorder, dementia (a progressive mental disorder characterized by failing memory and confusion), and acute kidney failure. R32's Discharge Minimum Data Set (MDS) completed 10/04/24 indicated she was discharged with an anticipated return to the facility. The MDS indicated she was discharged to a short-term hospital. R32's Entry MDS completed on 10/06/24 indicated she returned to the facility from an acute…
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 · D2024-10-31 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 36 residents. The sample included 13 residents with three 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 interviews, observations, and record reviews, the facility failed to ensure Resident (R)7 and R16's pressure-reducing interventions were implemented correctly when their low air-loss mattress pumps were set at an inappropriate weight for each resident. This deficient practice placed all affected residents at risk for complications related to skin breakdown and pressure ulcers. Findings included: - The Medical Diagnosis section within R7's Electronic Medical Records (EMR) noted diagnoses of cognitive communication deficit, muscle weakness, insomnia (difficulty sleeping), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). R7's Quarterly Minimum Data Set (MDS) dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-31 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 36 residents. The sample included 13 residents with two residents reviewed for catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 36 had a physician-ordered indication for an indwelling catheter and failed to provide adequate catheter care within the standards of care. This deficient practice placed R36 at risk of catheter-related complications and urinary tract infections (UTI). Findings included: - R36's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of muscle weakness, need for assistance with personal care, and hypertension (HTN-elevated blood pressure). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented R36 had an indwelling catheter during the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-31 · 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
The facility identified a census of 36 residents. The sample included 13 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure that as-needed (PRN) psychotropic (alters mood or thought) medication had a 14-day stop date or a specified duration with supporting physician documentation for Resident (R) 90's PRN psychotropic medications. This placed R90 at risk for unnecessary medication administration and possible adverse side effects. Findings included: - R90's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of muscle weakness, need for assistance with personal care, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, and dementia (a progressive mental disorder characterized by failing memory and confusion). The admission Minimum Data Set (MDS) was in progress not completed. R90's Care Area Assessment (CAA) was in progress and not completed. R90's Baseline Care Plan dated 10/26/24 documented that…
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 · D2024-10-31 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 36 residents. The sample included 13 residents with one resident reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure collaboration between the nursing home and hospice services to identify hospice-supplied services, supplies, medication, and equipment for Resident (R)7. This deficient practice placed R7 at risk for delayed services and uncommunicated care needs. Findings included: - The Medical Diagnosis section within R7's Electronic Medical Records (EMR) noted diagnoses of cognitive communication deficit, muscle weakness, insomnia (difficulty sleeping), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). R7's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of five indicating severe cognitive impairment. The MDS indicated both upper and lower extremity impairment on both sides. The MDS indicated she 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.
- Potential for harm · Ecited before2023-06-08 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 30. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to secure the main dining room kitchenette. This deficient practice placed five cognitively impaired independently mobile residents at risk for potential hazards or preventable accidents. The facility additionally failed to ensure Resident (R)22's Dycem (thin, rubber-like material that helps prevent sliding) was in her chair, as directed by the care plan, to prevent falls. This deficient practice placed R22 at risk for increased falls and injury. Findings Included: -On 06/07/23 at 09:37PM an inspection of the kitchenette after breakfast service revealed no doors to secure kitchenette or potentially hazardous equipment. The kitchenette was left unsecured and unsupervised. An inspection of the counter revealed a coffee pot left on top of a double pot warmer. The heater element still on and the glass coffee pot still warm. The kitchenette contained a functioning oven,…
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 17 citations
- Potential for harm · E2023-06-08 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 30 residents. The census included 12 residents. Based on observation and interview the facility failed to ensure safe and secure storage of medications when staff failed to securely lock one medication cart when the staff member was away from the cart. This deficient practice placed the facility's five independently mobile, cognitively impaired residents residents at risk accidental ingestion of medication and adverse reaction. Findings included: - During the initial tour of the facility on 06/06/23 at approximately 07:15 AM a medication cart was near the doorway of room [ROOM NUMBER]. This medication cart was not securely locked and was left unattended by Certified Medication Aide (CMA) R. Upon the return of CMA R to the cart, inspection of the cart revealed the medication cart contained numerous over the counter stock medications (medications that can be used without a prescription), and narcotic medication (medications or substances that relieves pain and induces…
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 before2023-06-08 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 with one kitchen and one kitchenette. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to storage of food and kitchenware. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns. Findings included: - On 06/06/23 at 07:39 AM observation in the kitchen's dry food storage room revealed two opened loaves of bread. The bags were not dated. On 06/06/23 at 07:41 AM observation in the kitchen's dry food storage room revealed two bags of opened hamburger buns. The bags were not dated, and one bag was open to air. On 06/06/23 at 07:48 AM observation in the kitchen's dry food storage room revealed one opened package of beef gravy mix. The package was not dated. On 06/07/23 07:24 AM an observation of the kitchenette revealed bowls stored on a tray, at the end of the countertop. The bowls were uncovered and not inverted. On 06/08/23 at 11:55 AM Dietary BB stated opened food should be labeled and dated. He further 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 · Ecited before2023-06-08 · tag F0880 — failed to prevent and control infections — patternProvide 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 30 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to ensure staff practiced standard infection control practices regarding appropriate hand hygiene and the facility failed to store oxygen tubing, nasal cannula (device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) and nebulizer mask in a sanitary manner. This placed the affected residents at risk for contagious illness. Findings included: - On 06/06/23 at 10:58 AM R10's undated nebulizer mask hung unbagged from the call light cord attached to the wall. R10's undated nebulizer mask rested against the wall and was attached to the nebulizer machine on the floor next to the bed. On 06/06/23 at11:53 AM Licensed Nurse (LN) G placed her hands in her jacket pocket after serving a plate of food to a resident. LN G then walked back to the dining serving area with hands in her pocket, removde her hands from her pcokets but did not perfomr hand hygiene. She grabbed a dessert…
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 · D2023-06-08 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 30 residents. The sample included 12 residents with one resident reviewed for self-administration of medication. Based on observation, record review, and interviews, the facility failed to ensure safe and appropriate self-administration of medication for Resident (R) 85. This deficient practice placed R85 at risk for unnecessary medication side effects and self-administration errors. Findings included: - R85's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of muscle weakness, repeated falls, need for assistance for personal care, and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). 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 that R85 required extensive assistance of one staff member for activities of daily living (ADLs). R85's ADL Functional/Rehabilitation…
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 · D2023-06-08 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 30 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 22 was free of physical restraints when staff placed R22 in an electric recliner, raised the footrest, then unplugged the recliner despite R22 was unable to manually lower the footrest on her own. This positioning of the footrest and R22's inability to move the footrest created a physical restraint as the footrest impeded R22's freedom of movement and mobility. This deficient practice placed R22 at risk for impaired mobility, rights, and at increased risk for restraint related accidents. Findings Included: - R22's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of repeated falls, dementia (progressive mental disorder characterized by failing memory, confusion), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of 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.
- Potential for harm · D2023-06-08 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 30 residents. The sample included 12 residents with 12 residents reviewed for comprehensive care plans. Based on observation, record review, and interviews, the facility failed to develop person-centered comprehensive care plan for Resident (R) 20 related to his ability to transfer using a transfer bar. This deficient practice placed R20 at risk of injuries related to unmet or uncommunicated needs. Findings included: - R20's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of abnormal involuntary movements, muscle weakness, abnormalities of gait and mobility, lack of coordination, cognitive communication deficit, and other reduced mobility. The admission Minimum Data Set (MDS) dated [DATE] lacked a cognitive assessment for R20. The MDS documented that R20 required limited assistance of one staff member for transfers and activities of daily living (ADLs). The Quarterly MDS dated 05/12/23 documented a staff interview which documented moderately…
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 · D2023-06-08 · 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. The sample included 12 residents with 12 reviewed for care plan revisions. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)27's plan of care was updated to include exercises to prevent a decline in his range of motion (ROM) and functional abilities for self-care. This deficient practice placed R27 at risk for decline in ROM and contractures (abnormal permanent fixation of a joint) due to uncommunicated care needs. Findings included: - The Medical Diagnosis section within R27'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), spondylosis (an age-related condition where the joints and cartilage lined discs of the neck are affected), benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections), paraplegia (paralysis characterized by motor or sensory loss in the lower limbs…
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 before2023-06-08 · 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 Medical Diagnosis section within R6's Electronic Medical Records (EMR) included diagnoses of benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections), 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), chronic kidney disease, major depressive disorder (major mood disorder), insomnia (difficulty sleeping), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dysphagia (swallowing difficulty), and dementia (progressive mental disorder characterized by failing memory, confusion). A review of R6's Annual Minimum Data Set (MDS) dated 04/28/23 indicated a Brief Interview for Mental Status (BIMS) of five indicating severe cognitive impairment. The MDS indicated he required extensive assistance from two staff for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-08 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 30. The sample included 12 residents with one reviewed for decreased range of motion (ROM). Based on observation, record review, and interviews, the facility failed to ensure Resident (R)27 received services to prevent a decline in his ROM and functional abilities for self-care. This deficient practice placed R27 at risk for decline in ROM and contractures (abnormal permanent fixation of a joint). Findings included: - The Medical Diagnosis section within R27'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), spondylosis (an age-related condition where the joints and cartilage lined discs of the neck are affected), benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections), paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), and cognitive communication deficit. A review of R27's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-08 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 30 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to monitor urine output (an indication of proper fluid intake or the presence of a problem and a common parameter of kidney function) and provide catheter (a tube placed in the bladder to drain urine into a collection bag) care to Resident (R) 8, who had a diagnosis of a neurogenic bladder (urinary condition where there is a lack bladder control due to a brain, spinal cord or nerve problems) and required the use of an indwelling catheter. This placed R8 at risk for infection and urinary catheter complications. The facility further failed to implement individualized toileting plans or attempt a toileting program related to bowel and bladder incontinence for R12. This deficient practice placed R12 at risk for complications related to incontinence. Findings included: - The electronic medical record (EMR) for R8 documented diagnoses of obstructive and reflux…
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 · D2023-06-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 30 residents. The sample included 12 residents with one resident reviewed for respiratory services. Based on observation, record review, and interviews, the facility failed the facility failed to store oxygen tubing, nasal cannula (device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) and nebulizer mask in a sanitary manner for Resident (R) 10. This deficient practice placed R10 at increased risk to develop a respiratory infection. Findings included: - R10's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of moderate persistent asthma (disorder of narrowed airways that caused wheezing and shortness of breath) and chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of 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.
- Potential for harm · Dcited before2023-06-08 · 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
The facility identified a census of 30 resident. The sample included 12 residents with five reviewed for unnecessary medications. Based on record review, observations, and interviews, the facility failed to provide a stop-date for Residents(R)25's as needed (PRN) antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression) used as a sleep aid. This deficient practice placed R25 at risk for unnecessary medications and side effects. Findings Included: - The Medical Diagnosis section within R25's Electronic Medical Records (EMR) included diagnoses of major depressive disorder (major mood disorder), insomnia (difficulty sleeping), restless leg syndrome (a condition that causes an uncontrollable urge to move the legs, usually because of an uncomfortable sensation), heart failure, and acute kidney disease. A review of R25's Quarterly Minimum Data Set (MDS) dated 04/28/23 indicated a Brief Interview for Mental Status (BIMS) of 12 indicating mild cognitive impairment. The MDS indicated she could perform her activities of daily living…
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 before2021-11-02 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 37 residents. The facility identified one Resident (R)13, on transmission-based precautions. Based on observation, interview, and record review, the facility failed to ensure the housekeeping staff cleaned a contact precaution room in a sanitary manner to ensure effective/appropriate disposal of the trash in the room and the cleaning cloths in the appropriate receptacle. These failures had the potential for affect all residents in the facility. Findings included: - The physician Progress Note, dated 11/01/21, for Resident (R)13, included a diagnosis of clostridium difficile (contagious bacteria characterized by foul smelling frequent bowel movements). On 11/02/21 at 10:55 AM, R13's room observed to have a covered bin with a red bag and a covered bin with a yellow bag near the room door. A sign on the door indicated contact enteric (intestinal) precautions. On 11/02/21 at 10:56 AM, Housekeeping staff V identified that R13 was on precautions for clostridium difficile. On 11/02/21 at 10:58 AM, Housekeeping staff V placed trash from R13's bathroom into…
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 before2021-11-02 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 37 residents with 12 residents selected for review, including seven residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to thoroughly investigate to determine contributing factors and causes of the falls, and implement appropriate interventions following falls to prevent further falls for Residents (R)4, R7, R10, R12, and R22. Findings included: - The Order Summary Report, dated 10/04/21, for Resident (R)4, included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), repeated falls, atrial fibrillation (rapid, irregular heart beat), heart failure, polyneuropathy (the malfunction of many peripheral nerves throughout the body), and unsteadiness on feet. The significant Minimum Data Set, (MDS) dated [DATE], for R4 assessed her as having a Brief Interview of Mental Status (BIMS) score of eight, indicating moderately impaired cognition. R4 required extensive assistance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-11-02 · 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 reported a census of 37 residents with 12 selected for review, including two residents reviewed for Activities of Daily Living. Based on observation, interview, and record review, the facility failed to ensure one of the residents who was dependent on staff for personal hygiene, Resident (R)26, received appropriate assistance needed for trimming of his fingernails. Findings included: - The Order Summary Report, dated 10/04/21, included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and need for assistance with personal care. The Annual Minimum Data Set (MDS), dated [DATE], assessed Resident (R)26 with a Brief Interview of Mental Status (BIMS) score of six, indicating severe cognitive impairment. He did not reject care and required extensive assistance of one staff for his personal hygiene cares. The Activities of Daily Living [ADL] Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 07/19/21, revealed R26 required extensive assistance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-11-02 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 37 residents with 12 selected for review including two reviewed for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). Based on observation, interview, and record review, the facility failed to keep the drainage bag from touching directly on the floor and anchoring the catheter tubing for one of the residents, Resident (7) with a history of urinary tract infections (UTI), creating a risk for developing further UTI's. Findings included: - The Order Summary Report, dated 10/04/21, for Resident (R)7, included diagnoses of personal history of urinary tract infections, retention of urine, and obstructive and reflux uropathy (blockage in the urinary tract). The admission Minimum Data Set (MDS), dated [DATE], assessed R7 with a Brief Interview of Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. He required extensive assistance of two staff for toilet use, had an indwelling catheter in place, had a diagnosis…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2023-06-08 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 30 residents. Based on interview, and record review the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ), when the facility failed to submit staffing hour data for all nursing personnel by the required deadline. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2022 Quarter three documented the facility failed to have staff Registered Nurse (RN) hours on 04/16,22, 04/17/22, 05/28/22 and 06/11/22 for the quarter. The Time Detail Report was reviewed from 04/01/22 to 04/30/22 that revealed there was RN coverage on 04/16/22 for a total time of 13 hours. Review of the Exempt Nursing Staff Schedule for April 2022 revealed on 04/17/22 RN hours of 8.5 hours for Administrative Nurse LL. Review of the Exempt Nursing Staff Schedule for May 2022 revealed on 05/28/22 Administrative Nurse MM had eight hours RN clock time. Review of the Exempt Nursing Staff Schedule for June 2022 revealed a clock time…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to PIVOTAL HEALTH CARE — 9 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 | 2 of 5 | 3.9 | -1.9 vs chain |
| Health inspection | 2 of 5 | 3.4 | -1.4 vs chain |
| Staffing | 4 of 5 | 4.4 | -0.4 vs chain |
| Quality measures | 4 of 5 | 4.0 | ≈ chain avg |
The other 8 homes this chain runs (chain average 3.9★, 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 | Since |
|---|---|---|---|
| SCENIC DEVELOPMENT LLC | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2018 |
| SCENIC HOLDINGS LLC | Organization | DIRECT OWNERSHIP INTEREST | since 07/31/2022 |
| 3RK, LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 01/01/2021 |
| 5 R CATTLE, LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 12/01/2018 |
| CADET INVESTMENT LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 12/01/2018 |
| LMRAY, LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 12/01/2018 |
| POKY - 5R LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 07/31/2022 |
| POKY FEEDERS INC | Organization | INDIRECT OWNERSHIP INTEREST | since 12/01/2018 |
| WSG LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 12/01/2018 |
| ANDERSON, JORDAN | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2025 |
| ANDERSON, MARLENE | Individual | INDIRECT OWNERSHIP INTEREST | since 12/01/2018 |
| ANDERSON, WAYNE | Individual | INDIRECT OWNERSHIP INTEREST | since 12/01/2018 |
| GULLEDGE, SCOTT | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/01/2018 |
| GULLEDGE, TRAVIS | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| HOWARD, STEVEN | Individual | INDIRECT OWNERSHIP INTEREST | since 12/01/2018 |
| WOOD, GILBERT | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2018 |
| PIVOTAL HEALTH CARE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/17/2025 |
| ABBY, AMBER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/02/2026 |
| MARTIN, CAROLINE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/06/2023 |
| CURANA HEALTH OF MISSOURI-KANSAS LLC | Organization | ADP OF THE SNF | since 03/01/2023 |
| SUMMIT CARE, LLC | Organization | ADP OF THE SNF | since 12/01/2018 |
CMS files one row per role, so the 31 rows in the source record cover these 21 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.
This home reported $241K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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 175560. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-31, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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