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Swan Health At Overland Park

6505 W 103rd Street, Overland Park, KS 66212 · For profit - Limited Liability company · 44 certified beds · (913) 649-5110 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0602) — most recent Mar 2025Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation$79,050 in federal fines1 Medicare payment denial
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Mar 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $79,050 in federal fines (most recent 2025-09-18)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (67%) 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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's quality-measure rating runs 3 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 — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Urgent care / clinic
10561 Barkley St · (877) 509-3655 · Call to confirm hours
Pharmacy
10303 Metcalf Ave · (913) 642-3759 · Call to confirm hours
Grocery
10303 Metcalf Ave · (913) 361-8534 · Call to confirm hours
Park
10210 Glenwood St · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 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 fell from 3 to 1 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 rating1★
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 increased8.7%17.9%15.4%better
Long-stay residents who lose too much weight0.0%4.9%5.4%check this — see note marked star below the table
Long-stay residents with a catheter left in their bladder14.9%1.6%0.9%worse
Long-stay residents with a urinary tract infection0.0%2.9%2.0%better
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 injury0.0%4.3%3.3%check this — see note marked star below the table
Long-stay residents on antianxiety or hypnotic medication35.8%23.2%18.9%worse
Long-stay residents given the seasonal flu vaccine91.7%95.5%95.3%typical
Long-stay residents with pressure ulcers10.7%4.4%4.7%worse
Long-stay residents with worsening bladder/bowel control20.1%22.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table9.5%18.1%17.1%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.

0.35U.S. median 0.31
Therapy hours / resident / day
0.04hours / resident / day
Physical therapy
0.29hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.35 therapist hours per resident per day in 2026Q1 — more than 59% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 dischargenot 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 staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.99
RN hours/ resident / day
1.35
LPN hours/ resident / day
2.08
Aide hours/ resident / day
4.42
Total nurse hours/ resident / day
0.88
RN hoursweekends
66.7%
Total nursing turnover
81.3%
RN turnover

How full it usually is: this home is certified for 44 beds and averages 35.3 residents a day — about 80% occupied, or roughly 9 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 4.42 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.99 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.08 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 4.01 hrs/resident/day on weekends vs 4.59 on weekdays — 13% thinner on weekends. RN hours go from 1.04 to 0.88 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 67% is well above the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

11
deficiencies at the latest standard inspection (2025-05-06)
7
at the previous standard inspection (2023-09-27)

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

Inspection deficiencies

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

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

31 citations, most serious first. The 13 most serious are shown; the remaining 18 are one tap away and print in full.

  • Immediate jeopardy · J2025-03-03 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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 29 residents. The sample included three residents reviewed for feeding tubes. Based on record review and interviews, the facility failed to prevent the neglect of Resident (R) 1 when staff did not provide adequate monitoring and timely care and attention to R1's percutaneous endoscopic gastrostomy (PEG tube- feeding tube through the abdominal wall directly into the stomach) site, which became infected, her abdomen became swollen and inflamed, and her right lower abdomen developed darkening, which staff documented as bruising. On 02/18/25 at 05:34 AM, R1 had a swollen abdomen and a large palpable mass around the PEG tube, with pus noted coming from the site. Staff notified Consultant GG, who assessed R1, and a note at 08:40 AM documented R1 had cellulitis (skin infection caused by bacteria) surrounding her PEG tube site with the skin indurated (hardened, firm) and erythematous (redness). Six days later, on 02/24/25 at 12:13 PM, Licensed Nurse (LN) G documented R1's PEG tube…

    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
  • Actual harm · G2026-06-09 · 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

    Based on record review, observations, and interviews, the facility failed to provide the necessary care and services related to indwelling catheter care for Resident (R) 1 when staff removed the catheter, failed to reinsert a catheter and monitor to ensure adequate urine output. Additionally, staff failed to obtain physician involvement. R1 subsequently developed a change in condition and was diagnosed with urine retention, urinary tract infection, and acute kidney injury. Findings included:- R1's Electronic Medical Record (EMR) documented diagnoses of conversion disorder (a mental condition in which a person experiences blindness, paralysis, or other nervous system symptoms that cannot be explained by illness or injury) with seizures (violent involuntary series of contractions of a group of muscles) or convulsions (involuntary series of contractions of a group of muscles), encephalopathy (a broad term for any brain disease that alters brain function or structure), and cerebrovascular disease (a group of conditions that affect the blood vessels supplying blood to the brain). 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
  • Actual harm · G2025-09-18 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide 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 37 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to implement interventions to prevent further weight loss for Resident (R) 1. R1 was admitted to the facility on [DATE] and had a weight loss of 3.85% by 07/02/25 with no documented intervention or response to the loss. R1's weight further declined to a significant loss of 8.85% by 08/01/25 (more than 7.5% in three months) with no documented intervention or response from the facility until 08/14/25. This deficient practice resulted in a total significant weight loss of -11.15% for R1 from 06/06/25 to 08/20/25. Findings included:- R1's Electronic Medical Record (EMR) documented a diagnoses of nontraumatic subarachnoid hemorrhage (SAH- bleeding in the space just outside the brain), conversion disorder (a mental condition in which a person experiences blindness, paralysis or other nervous system symptoms that cannot be explained by illness or injury),…

    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 · F2025-05-06 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 32 residents. Based on observation, record review, and interview, the facility failed to provide consistent Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week. This placed all the residents who resided in the facility at risk of a lack of assessment and inappropriate care. Findings included: - A review of the facility's submitted Payroll Based Journaling (PBJ - Staffing Data Report) from 04/01/24 through 03/31/25 indicated the facility triggered for no RN coverage on 12 occasions (04/05/24, 4/12/24, 04/19/24, 06/08/24, 07/20/24, 07/21/24, 08/03/24, 08/17/24,11/11/24, 11/17/24, 11/23/24, and 12/09/24). Upon review of the facility's working schedules and daily posted staffing revealed that no accounted RN hours for eight of the twelve days triggered (04/05/24, 04/12/24, 04/19/24, 06/08/24, 07/20/24, 07/21/24, 08/03/24, and 08/17/24). The facility was not able to provide documentation for the eight missing days of RN coverage as requested on 05/06/25. On 05/06/25 at 10:35 AM, Administrative Nurse D stated that both…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-05-06 · tag F0838 — failed to assess facility resources and resident needs — widespread
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 32 residents. The sample included 12 residents. Based on interviews and record reviews, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during both day-to-day operations and emergencies. This failure affected all 32 residents residing in the facility. Findings Included: - On 05/05/25, Administrative Staff A provided a Facility Assessment updated 03/01/25. A review of the assessment revealed the following: The assessment identified the required staffing needs per day but failed to identify the specific staffing needs for days, nights, and weekend shifts. On 05/05/25, a review of the facility's Payroll Based Journaling (PBJ - Staffing Data Report) from 04/01/24 to 03/31/25 revealed excessively low weekend staffing triggered in all four quarters. On 05/06/25 at 01:30 PM, Administrative Nurse D stated the facility assessment did not separate the hours required by shift but just showed the required hours as a total. She stated the facility assessment was updated…

    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 · F2025-05-06 · tag F0851 — widespread
    Electronically 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 reported a census of 32 residents. The sample included 12 residents. Based on record review and interviews, the facility failed to submit accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ - Staffing Data Report), when the facility failed to submit accurate weekend staffing coverage hours. This placed the residents at risk for unidentified and ongoing inadequate staffing. Findings included: - A review of the facility's submitted PBJ data from 04/01/24 through 03/31/25 indicated the facility triggered for excessively low weekend staffing for Fiscal Year (FY) Quarter Three 2024, FY Quarter Four 2024, FY Quarter One 2025, and FY Quarter Two 2025. A review of the facility's working schedule, time sheets/punches, and posted staffing hours indicated no gaps or loss of hours. An inspection of the working schedule revealed weekend call-offs documented with administrative nurse coverage. On 05/05/25, a review of the Facility Assessment updated 03/01/25 revealed the facility did not differentiate the required nursing hours 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-05-06 · tag F0881 — failed to use antibiotics responsibly — widespread
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 32 residents. The sample included 12 residents. Based on record review and interviews, the facility failed to develop and implement the core elements of antibiotic stewardship to ensure an effective infection prevention and control program, including antibiotic stewardship for residents in the facility. Findings included: - Review of the Infection Control Log for tracking and trending infections from May 2024 through April 2025, lacked evidence of tracking and identification of possible infection outbreaks at the facility. The infection log lacked identification of the facility-acquired infections. On 05/06/25 at 09:06 AM, Administrative Nurse D, the facility's Infection Preventionist, stated she did not track the antibiotic use in the facility to monitor for a possible infection outbreak. The facility's Infection Prevention Plan policy, dated 2025, documented the Infection Prevention and Control Program was designed to improve the quality of care for patients while reducing the risk of acquired Healthcare-Associated Infections (HAIs) 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-06 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 32 residents. Based on observations, record review, and interviews, the facility failed to ensure safe medication storage with three of the five medication carts. This deficient practice placed the residents at risk for diversion and ineffective medication regimen. Findings Included: - On 05/04/25 at 10:00 AM, an inspection of the facility revealed three unlocked and unsupervised medication carts on the facility's 200 hallway. An inspection of the medication carts revealed resident medications, stock medications, and medicated ointments stored in the carts. On 05/04/25 at 10:06 AM, Licensed Nurse (LN) G stated she was away from the medication cart for only five minutes, but stated she should have locked them before leaving them. She secured the medication carts. On 05/04/25 at 10:07 AM, LN I stated all the carts were to be locked when staff were away from them. LN I secured the other two carts and returned to the nurse's desk. On 05/06/25 at 01:32 PM, Administrative Nurse D stated staff were expected to lock the medication and treatment carts when…

    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 · D2025-05-06 · 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 32 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observations, record review, and interviews, the facility failed to ensure Residents (R) 19 and R8 remained free from unnecessary psychotropic (alters mood or thought) medications and chemical restraint (use of medication to control behaviors). This deficient practice placed both residents at risk for sedation and chemical restraint. Findings Included: - The Medical Diagnosis section within R19's Electronic Medical Records (EMR) included diagnoses of quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), muscle weakness, dysphagia (difficulty swallowing), and chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). R19's Quarterly Minimum Data Set (MDS) dated 02/04/25 noted a Brief…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-06 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to complete the Care Area Assessment (CAA) analysis of findings, related to a Comprehensive Minimum Data Set (MDS), for two residents, Residents (R) 12 and R20, in order to address the underlying cause, risk factors, and other contributing factors to ensure the resident received care based on their individual needs. This placed these residents at risk for impaired care and decreased quality of life due to unidentified care needs. Findings included: - R12's admission MDS dated 11/07/24 23 triggered the CAA for functional abilities (self-care mobility), urinary incontinence and indwelling catheter, pressure ulcer, and nutritional status. All triggered CAA's lacked completion with an analysis of findings. R20's admission MDS dated 11/19/25 triggered the CAA for functional abilities (self-care mobility), urinary incontinence and indwelling catheter, pressure ulcer, psychotropic (alters mood or thought) drug use, falls, 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 before2025-05-06 · 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 32 residents. The sample included 12 residents, with five sampled residents reviewed for unnecessary medications. Based on observations, record review, and interviews, the facility failed to ensure the Consultant Pharmacist's (CP) recommended a Centers for Medicare and Medicaid (CMS) approved indication related to Resident (R) 19's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication. This deficient practice placed R19 at risk of unnecessary medication administration and related complications. Findings Included: - The Medical Diagnosis section within R19's Electronic Medical Records (EMR) included diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), muscle weakness, dysphagia (difficulty swallowing), and chronic obstructive…

    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 before2025-05-06 · 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

    The facility identified a census of 32 residents. The sample included 12 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the physician was notified of blood sugars outside the physician ordered parameters for Resident (R) 12 and the facility failed to ensure antihypertensive (medication used to treat high blood pressure) medication was administered per the physician ordered parameters for R16. These deficient practices placed these residents at risk for unnecessary medication administration and possible adverse reactions. Findings included: - R12's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid) and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The admission Minimum Data Set (MDS) dated 11/07/24 documented a Brief Interview of Mental Status (BIMS) score of 15,…

    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 · D2025-05-06 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 32 residents, with one resident on puree textured diets. Based on observations, interviews, and record review, the facility failed to follow nutritionally approved recipes during the preparation of the facility's puree-based meals. This deficient practice placed one resident at risk for complications related to nutritional impairment. Findings included: - On 05/05/25 at 10:59 AM, Dietary Staff CC placed one serving of cooked parmesan chicken into the food processor machine and then started the machine. Dietary Staff CC then poured water into the food processor with the chicken. Dietary Staff CC checked the consistency. Dietary Staff CC washed the food processor bowl. Dietary Staff CC placed one serving of cooked spaghetti with marinara sauce into the food processor and then started the machine. Dietary Staff CC then poured water into the food processor with the spaghetti and then added the thickener into the processor bowl. Dietary Staff CC washed the food processor bowl, then placed one serving of cooked peas into the food processor and started…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · E2025-03-03 · tag F0602 — failed to protect residents from theft of their belongings — pattern
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 29 residents and 11 residents with trust accounts. The sample included three residents who were reviewed for misappropriation. Based on observation, record review, and interviews, the facility failed to ensure residents with trust accounts managed by the facility remained free from misappropriation when Administrative Staff B misappropriated funds from the resident trust fund account. This deficient practice placed all residents with trust accounts managed by the facility at risk for misappropriation, financial instability, and impaired rights. Findings included: - The facility's undated RFMS [Resident Funds Management Systems] Investigation, documented on 12/11/24 the facility initiated an investigation after finding credit card fraud on the company credit card attributed to Administrative Staff B. The facility noted several large checks from the resident funds account written to Administrative Staff B with withdrawals not matching up with the written checks. On 12/16/24, Administrative Staff C flew in to assist with the audit of the facility'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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-03 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 29 residents. Based on record review and interviews, the facility failed to notify Resident (R) 1's representative of the plan of care changes. This deficient practice had the risk of miscommunication between R1, their representative, and the facility. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of encounter for attention to gastrostomy (G-tube: tube surgically placed through an artificial opening into the stomach) and anoxic brain damage (brain injury that occurs when the brain is deprived of oxygen for too long). The admission Minimum Data Set (MDS) dated 10/14/24, documented R1 had a feeding tube and received 51% or more total calories and 501 cubic centimeters (cc) or more of fluids through tube feeding daily. The Quarterly MDS dated 01/14/25, documented R1 had a feeding tube and received 51% or more total calories and 501 cc or more of fluids through tube feeding daily. The Feeding Tube Care Area Assessment (CAA) dated 10/14/24, lacked an analysis of findings. R1's Care Plan dated 12/17/24, documented R1…

    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 · D2025-03-03 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 29 residents and 11 residents with trust accounts. The sample included three residents who were reviewed for misappropriation. Based on observation, record review, and interviews, the facility failed to report the suspicion of misappropriation of resident funds to the State Agency (SA) and law enforcement within the required timeframe. This deficient practice placed all residents with trust accounts managed by the facility at risk for unidentified and ongoing misappropriation. Findings included: - The facility's undated RFMS [Resident Funds Management Systems] Investigation, documented on 12/11/24 the facility initiated an investigation after finding credit card fraud on the company credit card attributed to Administrative Staff B. The facility noted several large checks from the resident funds account written to Administrative Staff B with withdrawals not matching up with the written checks. On 12/16/24, Administrative Staff C flew in to assist with the audit of the facility's RFMS account. On 12/17/24, the facility identified several withdrawals…

    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 · D2023-09-27 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 27 residents. The sample included 12 residents with one resident reviewed for accidents. Based on observation, record review, and interviews, the facility failed to routinely reassess the continued use of upper half siderails to assure safety for Resident (R) 13. This placed the resident at risk for injury related to incorrect or unsafe use of side rails. Findings included: - R13's clinical medical record documented diagnoses of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord), hypertension (elevated blood pressure), and encephalopathy (inflammatory condition of the brain). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition and R13 was unable to complete the interview. The MDS documented that R13 was dependent on one staff member for assistance with activities of daily living (ADLs). The Quarterly MDS dated 06/30/23…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-27 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    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 27 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure staff possessed the appropriate competencies to safely administer medications per the standards of practice when licensed nursing staff failed to clarify Resident (R) 19's antihypertensive (class of medication used to treat high blood pressure) medication order. This deficient practice placed R19 at risk for medication errors. Findings included: - R19's clinical record documented diagnoses of hypertension (elevated blood pressure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought). The admission Minimum Data Set (MDS) dated [DATE] documented R19's cognition was severely impaired. The MDS…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-27 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 27 residents. The sample included 12 residents with five residents reviewed unnecessary medications. Based on observation, record review, and interviews, the facility failed to acknowledge and follow the Consultant Pharmacist's (CP) recommendations to complete a gradual dose reduction (GDR) or provide an indicated rationale for Resident (R)17's psychotropic (a class of medications which affect mood or thoughts) medications. This deficient practice placed R17 at risk for ineffective treatment and unnecessary side effects. Findings Included: - The Medical Diagnosis section within R17's medical record included diagnoses of conversion disorder (a mental condition in which a person experiences blindness, paralysis or other nervous system symptoms that cannot be explained by illness or injury), seizures (involuntary series of contractions of a group of muscles), major depressive disorder (major mood disorder), and chronic respiratory failure. R17's Annual Minimum Data Set (MDS) completed 06/28/23 noted a Brief Interview for Mental Status (BIMS)…

    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 before2023-09-27 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 27 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 19's medications had an indication for administration. This deficient practice placed R19 at risk for unnecessary medication use and unwarranted side effects. Findings included: - R19's clinical record documented diagnoses of hypertension (elevated blood pressure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought). The admission Minimum Data Set (MDS) dated [DATE] documented R19's cognition was severely impaired. The MDS documented that R19 was dependent on one staff members assistance for activities of daily living (ADLs). The MDS documented R19 had received antidepressant (class 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-27 · 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 27 residents. The sample included 12 residents with five residents reviewed unnecessary medications. Based on observation, record review, and interviews, the facility failed to complete a gradual dose reduction (GDR) or provide a rationale for contraindication related to Resident (R)17 and R19's psychotropic (a class of medications which affect mood or thoughts) medications. The facility additionally failed to provide anindication for use on R19's Haldol (antipsychotic medication- used to treat major mental conditions which cause a break from reality) medication and Lexapro (depression medication). This deficient practice placed both at risk for ineffective treatment and unnecessary side effects. Findings Included: - The Medical Diagnosis section within R17's medical record included diagnoses of conversion disorder (a mental condition in which a person experiences blindness, paralysis or other nervous system symptoms that cannot be explained by illness or injury), seizures…

    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 · D2023-09-27 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    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 27 residents. The sample included 12 residents with five reviewed for influenza (highly contagious viral infection) and pneumococcal (type of bacterial infection) immunizations. Based on record review and interviews, the facility failed to provide pneumococcal vaccinations or informed refusals for Residents (R)19. This deficient practice placed R19 at risk for complication related to pneumonia. Findings included: - On 09/26/23 at 03:45 PM a review of influenza and pneumococcal immunizations was completed for R9, R17, R19, R23, and R78. The review revealed that R19 lacked evidence indicating he or his representative was offered, consented, refused, or had received the pneumonia vaccination. On 09/27/23 at 10:58AM Administrative Nurse D stated R19's pneumonia vaccination documentation could not be found. She stated she called R19's representative and completed the consent/declination form on 09/27/23. She stated R19's representative declined for him to receive the pneumonia…

    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 · E2022-02-07 · 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 23 residents. Based on observations, record reviews, and interviews, the facility failed to ensure proper personal protective equipment (PPE- gloves, gowns, face shields and/or eye glasses/goggles) usage and failed to ensure adequate hand hygiene was performed. This deficient practice had the risk to spread illness and infection to all residents. Findings included: - On 02/01/22 at 07:05 AM, Licensed Nurse (LN) G and an unidentified male staff member stood at the nurse's station. It was noted that they were not wearing a face mask. An unidentified female staff member sat behind the nurse's station with her face mask pulled below her chin. The staff members were within six feet of each other. On 02/07/22 at 08:56 AM, LN I donned (put on) gloves then donned gown. He entered Resident (R) 14's room for medication pass then exited room. He doffed (remove) gloves then gown and performed hand hygiene. On 02/07/22 at 09:05 AM, LN H donned gloves and prepared medications for administration for R5. After medication preparation, he started donning a gown 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-02-07 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 23 residents. The sample included 12 residents with three residents sampled for beneficiary notification. Based on record review and interviews, the facility failed to provide notices for Medicare Non-Coverage to resident and/or resident's family/Durable Power of Attorney (DPOA- document that designated a person who made health care decisions for resident if they were no longer able to make their own decisions) for Resident (R) 3, R124, and R125. This deficient practice had the risk for miscommunication between resident/resident family and facility and potential for missed skilled services and unanticipated charges. Findings included: - Medicare Liability Notice, CMS 101123- Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) were requested for R3, R124, and R125. Facility was unable to provide the requested documents. In an interview on 02/02/22 at 01:29 PM, Administrative Nurse D stated the business office manager quit working at the facility recently and facility was unable…

    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 · D2022-02-07 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 23 residents. The sample included 12 residents; one resident reviewed for hospitalization. Based on observations, record reviews, and interviews, the facility to notify the state ombudsman of transfers and failed to provide a written notification of transfers to Resident (R) 13's family/durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to) in a practicable amount of time. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare services. Findings included: - R13 was transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. R13's medical record documented diagnoses of acute respiratory failure (serious condition that develops when the lungs can't get enough oxygen into the blood), and persistent vegetative state (comatose patient continues to be unable to communicate or respond to stimuli).…

    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 · D2022-02-07 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 23 residents. The sample included 12 residents; two residents sampled for accidents. Based on observations, record reviews, and interviews, the facility failed to revise the care plan with interventions to prevent further falls for Resident (R) 5. This deficient practice had the risk for further falls, possible injuries from falls, and unwarranted physical complications. Findings included: - R5's medical record documented diagnoses of acute and chronic respiratory failure (serious condition that develops when the lungs can't get enough oxygen into the blood), dependence on respirator status, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). The admission Minimum Data Set (MDS) dated 11/18/21, documented R5 had a Brief Interview for Mental Status of 13. R5 required extensive physical assistance with one staff member for bed mobility and dressing; total physical dependence with…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-02-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    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 identified a census of 23 residents. The sample included 12 residents; two residents sampled for accidents. Based on observations, record reviews, and interviews, the facility failed to implement and follow-through with interventions after falls to prevent further falls for Resident (R) 5. This deficient practice had the risk for further falls, possible injuries from falls, and unwarranted physical complications. Findings included: - R5's medical record documented diagnoses of acute and chronic respiratory failure (serious condition that develops when the lungs can't get enough oxygen into the blood), dependence on respirator status, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). The admission Minimum Data Set (MDS) dated 11/18/21, documented R5 had a Brief Interview for Mental Status of 13. R5 required extensive physical assistance with one staff member for bed mobility and dressing; total…

    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 before2022-02-07 · 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 reported a census of 23 residents. The sample included 12 residents; five residents sampled for unnecessary medication review. Based on observations, record reviews, and interviews, the facility failed to ensure consistent medication administration for Resident (R) 5, failed to ensure ordered medications had diagnoses for R5, and failed to ensure nursing staff notified the physician when blood glucose levels were outside of ordered parameters for R8. This deficient practice had the risk for unwarranted physical complications and unnecessary medication use. Findings included: - R5's medical record documented diagnoses of acute and chronic respiratory failure (serious condition that develops when the lungs can't get enough oxygen into the blood), dependence on respirator status, Chronic Obstructive Pulmonary Disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and depression (abnormal…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-02-07 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 23 residents. The facility had one main kitchen. Based on observation, record review and interview, the facility failed to store food (opened food items in dry storage and the walk-in freezer that were not in a sealed package the was labeled or dated), and failed to properly wash and sanitize food equipment before use. This deficient practice left residents at risk for food borne illness and contamination. Findings included: - During the initial tour of the facility kitchen on 02/01/22 at 07:22 AM, observation in the dry storage area revealed an opened package of noodles that was wrapped in plastic wrap and not in a sealed bag, and there was no labeling or date opened on the package. There was also an opened bag of rice that had been wrapped in plastic wrap that was not in a sealed bag, and there was no label or date opened on the package. The walk-in freezer had an opened bag of ham cubes that was not placed in a sealed bag, or labeled with an opened date. The walk-in freezer also had an opened bag with eight salmon fillets which were not in…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2025-05-06 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 32 residents. The sample included 12 residents. Based on record review and interview, the facility failed to update its daily posted staffing form to provide accurate daily staffing information. Findings included: - On 05/04/25 at 10:05 AM, an inspection of the facility revealed posted staffing documentation on the wall in the cafeteria area. An inspection of the documentation revealed the document was dated 04/29/25. At 10:05 AM, Licensed Nurse (LN) H stated the form should be updated daily by the nursing administrators, but had not been updated since last week. On 05/05/25 at 0745 AM, an inspection of the posted staffing form revealed a date of 04/29/25. On 05/06/25 at 01:32 PM, Administrative Nurse D stated the form was to be updated daily with the correct information on it. She stated that Administrator A updated and posted the forms daily. On 05/06/25 at 01:32 PM, Administrator A stated she had been off since last week and wasn't able to update the forms. The facility's Posting Direct Care Daily Staffing Numbers policy, revised 08/2022,…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-09-27 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 27 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to post the previous state inspection information in a location accessible to residents and visitors. Findings included: - On 09/26/23 at 01:30 PM unable to locate previous survey results for the facility. On 09/26/23 at 01:45 PM Administrative Nurse D stated she had the past survey results in a folder in her office that was available to residents and their representatives upon request. Administrative Nurse D stated prior to the COVID-19 (highly contagious respiratory virus) health emergency, the survey results were available out in the common area. On 09/26/23 at 01:49 PM Administrative Staff A stated she had a copy of the past survey results available in her office for residents or their representatives to review upon request. Administrative Staff A stated she would place the past survey results in a common area for visitors. The facility was unable to provide a policy related to past survey results availability. The facility…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$79,050 in federal fines across 3 penalties. 1 Medicare payment denial on record.

  • $6,578 — penalty dated 2025-09-18
  • $55,003 — penalty dated 2025-03-03
  • $17,469 — penalty dated 2023-11-08
  • Medicare payment denial — starting 2023-11-28 for 7 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleShareSince
HHN HOLDCO LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 08/25/2024
MYEROWITZ, NETANELIndividualINDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/08/2025
GEHA, CHRISTOPHERIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2024
WORS, PATRICIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/25/2024

CMS files one row per role, so the 11 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

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

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 175240. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-06, 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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