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Via Christi Village Pittsburg

1502 E Centennial, Pittsburg, KS 66762 · Non profit - Corporation · 96 certified beds · (620) 235-0020 Medicare & Medicaid certified

Call the home — (620) 235-0020 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited May 2024Behavioral-health or dementia-care citations — no harm found (F0744, F0758)1 actual-harm citation1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$13,397 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2024
  • it has 1 actual-harm citation
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $13,397 in federal fines (most recent 2024-05-06)
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (89%) 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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2711 S Rouse St · (620) 232-5705 · Call to confirm hours
Pharmacy
1011 E Centennial Dr · (620) 308-7110 · Call to confirm hours
Grocery
1011 E Centennial Dr · (620) 308-7111 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
802 E Centennial Dr · (620) 231-3293

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 2 of 5
Long-stay residentspeople who live here 1 of 5
Short-stay residentsrehab / post-hospital 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 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 rating3★
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 increased19.9%17.9%15.4%worse
Long-stay residents who lose too much weight4.0%4.9%5.4%better
Long-stay residents with a catheter left in their bladder0.7%1.6%0.9%better
Long-stay residents with a urinary tract infection4.5%2.9%2.0%worse
Long-stay residents with depressive symptoms1.2%6.5%6.5%better
Long-stay residents who were physically restrained1.5%0.0%0.1%worse than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury7.9%4.3%3.3%worse
Long-stay residents whose ability to walk worsened22.5%16.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication21.9%23.2%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.5%95.3%typical
Long-stay residents with pressure ulcers3.0%4.4%4.7%better
Long-stay residents with worsening bladder/bowel control28.0%22.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table31.1%18.1%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.6%1.9%1.4%better
Short-stay residents given the seasonal flu vaccine83.3%73.8%79.4%typical
Short-stay residents rehospitalized after admission34.7%22.4%22.6%worse
Short-stay residents with an outpatient ER visit7.0%11.5%12.0%better
Long-stay hospitalizations per 1,000 resident days1.321.801.67better
Long-stay outpatient ER visits per 1,000 resident days2.032.131.80worse

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 103 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.8%U.S. median 51.5%
Got home and stayed home
10.0%U.S. median 10.7%
Went back to hospital
78.8%U.S. median 56.6%
Met the expected recovery
0.31U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 78.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 66 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 0.31 therapist hours per resident per day in 2026Q1 — more than 51% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 28% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF48.8%CMS range 38.6–55.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.0%CMS range 7.5–14.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge78.8%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge65.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge63.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 stay1.1%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.2%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.3%CMS range 5.3–14.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.831.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.48
RN hours/ resident / day
0.56
LPN hours/ resident / day
3.01
Aide hours/ resident / day
4.06
Total nurse hours/ resident / day
0.20
RN hoursweekends
88.8%
Total nursing turnover
90.9%
RN turnover

How full it usually is: this home is certified for 96 beds and averages 83.6 residents a day — about 87% occupied, or roughly 12 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 4.06 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.01 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 3.77 hrs/resident/day on weekends vs 4.18 on weekdays — 10% thinner on weekends. RN hours go from 0.60 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 89% 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

12
deficiencies at the latest standard inspection (2024-10-21)
11
at the previous standard inspection (2022-12-19)

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.

29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.

  • Immediate jeopardy · J2024-05-06 · 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 reported a census of 81 residents. The sample included three residents reviewed for neglect. Based on observations, record review, and interview, the facility failed to prevent the staff neglect of Resident (R) 1. On 11/27/23 at 08:45 AM Certified Medication Aide (CMA) R entered cognitively impaired R1's room and observed R1 on the floor with her legs extended in the doorway of the closet. CMA R administered medications to R1 while she remained on the floor, and then left the resident's room. CMA R failed to report to any staff member that R1 was on the floor. At 12:45 PM, four hours later, CNA M heard noises coming from R1's room and when she entered the residents' room, she observed R1 sitting on the floor next to her bed. CNA M asked Housekeeping Staff U, who was also in the room, to immediately get Licensed Nurse (LN) G. The nurse assessed R1 and noted the resident had pain in her left hip, her left leg was rotated outward and appeared to be shorter than her right leg. R1 was transported to 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Actual harm · Gcited before2021-05-13 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 74 residents with 22 selected for review, which included eight residents reviewed for accidents. Based on observation, interview, and record review the facility failed to ensure appropriate fall interventions were in place by determining the causal factors of the fall for four of the eight sampled residents. Of these Resident (R) 47 fell and sustained a nasal fracture and forehead laceration which required 11 sutures, with R2 and R33 experiencing repeated falls. The facility further failed to investigate and develop interventions for one of the eight residents, R51 who sustained repeated skin tears to the arms on three occasions. Findings included: - Review of R 47's Physician Order Sheet, dated 04/07/21, revealed diagnoses that included repeated falls, diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) with polyneuropathy (nerve damage in multiple nerves), hypertension (elevated blood pressure) and dementia…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-21 · tag F0553 — failed to let residents help plan their care — pattern
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    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 74 residents with 20 residents selected for review. Based on observation, interview, and record review, the facility failed to provide care plan meetings for four Residents (R) 13, R2, R7 and R57, as required. Findings included: - Review of Resident (R)2's medical record revealed diagnosis that included end stage renal (kidney) disease. The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. The resident received dialysis services (a procedure to remove excess toxins and waste products from the blood when the kidneys fail). The Quarterly MDS dated 08/15/24, indicated a BIMS score of 12, which indicated moderate cognitive impairment. The resident received dialysis services. The Cognitive Loss Care Area Assessment (CAA), dated 02/29/24, assessed the resident received dialysis treatments and was at risk for nutritional and fluid volume imbalance. The Care…

    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 · E2024-10-21 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working safely.
    What the surveyor found here — the official record, unedited, may be distressing

    The facility reported a census of 74 residents. Based on observation, interview, and record review, the facility failed to ensure all resident equipment in one of the four neighborhoods were in clean, safe condition, regarding one toilet seat riser with legs and handles. Findings included: - During a brief environmental tour of C Court, on 10/14/24 at 09:25 AM, the following areas of concern were noted: A toilet seat riser had multiple rusty areas over all four legs. The plastic toilet seat had a crack where it met residents' buttocks area. On 10/21/24 at 09:49 AM, Housekeeping/Maintenance Staff U stated the toilet seat riser needed to be thrown away.Housekeeping/Maintenance Staff U stated the facility had extra toilet seat risers available for when one needed replaced. The facility lacked a policy for the maintenance and upkeep of resident equipment. The facility failed to ensure all resident equipment in the C Court neighborhood was clean and in safe condition.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-21 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — the official record, unedited, may be distressing

    The facility reported a census of 74 residents. Based on observation, interview, and record review, the facility failed to ensure a clean environment in one of the four neighborhoods regarding soiled, stained privacy curtains in a shower room in one of the four neighborhoods. Findings included: - During a brief environmental tour of C Court, on 10/14/24 at 09:25 AM, the following areas of concern noted: Two privacy curtains contained multiple areas which were dirty and stained. On 10/21/24 at 09:49 AM, Housekeeping/Maintenance Staff U stated housekeeping was responsible for ensuring the privacy curtains in the shower rooms were clean. The privacy curtains needed to be washed or replaced. The facility lacked a policy regarding the maintenance/cleaning of the shower curtains. The facility failed to ensure a clean environment in one of the four neighborhoods regarding soiled, stained privacy curtains in a shower room in one of the four neighborhoods.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-21 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 reported a census of 74 residents with 20 residents sampled. Based on observation, interview, and record review, the facility failed to complete a comprehensive care plan for one Resident's (R)27's, regarding the care and maintenance of her personal humidifier. Findings included: - Review of Resident (R)27's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 01/18/24, documented the resident had a diagnosis of dementia with confusion and forgetfulness. The Quarterly MDS, dated 09/26/24, documented the resident had a BIMS score of one, indicating severe cognitive impairment. The care plan, revised 10/14/24, lacked staff instruction regarding the care and maintenance of 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-21 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 74 residents with 20 residents sampled. Based on observation, interview, and record review, the facility failed to review and revise the care plans for two Residents (R)59 and R 70, regarding footrests for their wheelchairs. Findings included: - Review of Resident (R)59's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. She utilized a wheelchair for mobility and was able to mobilize 150 feet with two turns with set-up assistance only. The Activities of Daily Living (ADL) Functional/Rehabilitation Care Area Assessment (CAA), dated 09/26/24, documented the resident required extensive assistance of one staff for mobility with the wheelchair. The Quarterly MDS, dated 07/04/24, documented the resident had a 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-21 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 74 residents with 20 residents included for review, which included two residents reviewed for activities of daily living. Based on observation, interview, and record review, the facility failed to ensure two Resident (R)13 and R37 received grooming assistance. Findings included: - Review of Resident (R)13's medical record revealed diagnoses that included hemiplegia (paralysis of one side of the body) after cerebral infarction (cerebrovascular accident (CVA) [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 artery to the brain). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15, which indicated normal cognitive function. R13 had functional limitation in range of motion impairment on one side of the upper and lower extremities. The Communication Care Area Assessment (CAA), dated 12/15/23, assessed the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-21 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    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 74 residents with 20 residents sampled, including two residents reviewed for positioning. Based on observation, interview, and record review, the facility failed to properly position two Residents (R)59 and R 70, regarding footrests for their wheelchairs. Findings included: - Review of Resident (R)59's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. She utilized a wheelchair for mobility and was able to mobilize 150 feet with two turns with set-up assistance only. The Activities of Daily Living (ADL) Functional/Rehabilitation Care Area Assessment (CAA), dated 09/26/24, documented the resident required extensive assistance of one staff for mobility with the wheelchair. The Quarterly MDS, dated 07/04/24, documented the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 74 residents with 20 residents sampled, including one resident reviewed for respiratory services. Based on observation, interview, and record review, the facility failed to properly clean and maintain a humidifier (a device for keeping the atmosphere moist in a room) in one Resident's (R)27's room. Findings included: - Review of Resident (R)27's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 01/18/24, documented the resident had a diagnosis of dementia with confusion and forgetfulness. The Quarterly MDS, dated 09/26/24, documented the resident had a BIMS score of one, indicating severe cognitive impairment. The care plan, revised 10/14/24, lacked staff…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-21 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 74 residents with 20 residents selected for review, which included one resident reviewed for dialysis (a procedure to remove excess toxins and waste products from the blood when the kidneys fail). Based on observation, interview, and record review, the facility failed to ensure staff provided assessment and monitoring for one Resident (R)2 who received dialysis three times a week. Findings included: - Review of Resident (R)2's medical record revealed diagnoses that included end stage renal (kidney) disease. The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. The resident received dialysis services (a procedure to remove excess toxins and waste products from the blood when the kidneys fail). The Quarterly MDS dated 08/15/24, indicated a BIMS score of 12, which indicated moderate cognitive impairment. The resident received dialysis services. The…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-21 · 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 reported a census of 74 residents with 20 residents selected for review, that included six residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure one Resident (R)2, received medications within the physician ordered parameters. Findings included: - Review of Resident (R)2's medical record revealed diagnoses that included end stage renal (kidney) disease. The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. The resident received dialysis services (a procedure to remove excess toxins and waste products from the blood when the kidneys fail). The Quarterly MDS dated 08/15/24, indicated a BIMS score of 12, which indicated moderate cognitive impairment. The resident received dialysis services. The Cognitive Loss Care Area Assessment (CAA), dated 02/29/24, assessed the resident received dialysis treatments…

    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
Show the remaining 17 citations
  • Potential for harm · Dcited before2024-10-21 · 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 reported a census of 74 residents with 20 residents sampled, that included six residents reviewed for unnecessary medication. Based on observation, interview, and record review, the facility failed to assess one Resident (R)44, for adverse effects of an antipsychotic (a class of medications used to treat psychosis and other mental emotional conditions). Findings included: - Review of Resident (R)44's medical record revealed diagnoses that included dementia (progressive mental disorder characterized by failing memory, confusion) with behavior disturbance, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear),and pseudobulbar affect (a neurological disorder that causes uncontrollable and inappropriate episodes of laughing or crying). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of one, which indicated severe cognitive impairment. The resident received antipsychotic…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-21 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    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 74 residents, with 20 sampled. Based on observation, interview and record review, the facility failed to use proper hand hygiene while completing wound care for one Resident (R)27. Findings included: - Review of Resident (R)27's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. She was at risk for the development of pressure ulcers (PU) and had no unhealed PU at the time of the assessment. The Pressure Ulcer/Injury Care Area Assessment (CAA), dated 01/18/24, documented the resident spent most of her time in her recliner and required assistance with positioning. The Quarterly MDS, dated 09/26/24, documented the resident had a BIMS score of one, indicating severe cognitive impairment. She was at risk for the development 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-07 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    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 83 residents. The sample included three residents reviewed for pain-controlled substance medication. Based on observation, interview, and record review, the facility failed to prevent a medication error when Licensed Nurse (LN) I failed to document in Resident (R)1's Electronic Health Records (EHR). On 02/28/24 at 06:00 AM, LN I administered oxycodone (opioids [narcotic analgesics]), five milligram (MG) tablet, as an as needed (PRN) pain medication. On 02/28/24 at 08:00 AM, two hours later, LN H administered R1's scheduled oxycodone, which was to be administered one hour prior to leaving for dialysis (a blood purifying treatment given when kidney function in not optimum), for pain. The facility failed to ensure no use of as needed (PRN) administered within a six-hour time frame of the scheduled doses, as ordered by the physician. This failure caused R1 to receive two doses of oxycodone, five mg, two hours apart. Findings Included: - The signed Physician Order Sheet (POS) for 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-12-19 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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 79 residents and one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to food storage. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns. Findings Included: - On 12/13/22 at 07:06AM an initial walkthrough of the facility's kitchen was completed. An inspection of the kitchen's walk-in refrigerator revealed that the air-conditioning unit was leaking clear liquid. The fluid was dripping down onto several shelves stored below the unit. An inspection of the shelves revealed two bags of collard greens, one box of cut okra, and one box of hot dogs were covered in ice. On 12/19/22 at 01:20PM Dietary Staff BB stated that staff should be going in an inspecting the storage areas daily for cleanliness and equipment function. He was not aware of the leak in the freezer unit but would report it to the director. A review of the facility's Food Storage policy dated 01/2019 indicated that all foods stored in the walk-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
  • Potential for harm · D2022-12-19 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 79 residents. The sample included 18 residents with one resident reviewed for dignity. Based on observations, interviews, and record reviews, the facility failed to provide Resident (R)5 with dignity during basic cares. This deficient practice placed the residents at risk for decreased psychosocial well-being. Findings Included: - The Medical Diagnosis section within R5's Electronic Medical Records (EMR) included diagnoses of cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth), epilepsy (brain disorder characterized by repeated seizures), intellectual disabilities, muscle weakness, Lennox-Gastuat syndrome (severe condition with recurrent epileptic seizures starting from early childhood), and dysphagia (swallowing difficulty). R5's Quarterly Minimum Data Set (MDS) dated 09/15/22 noted a Brief Interview for Mental Status (BIMS) could not be completed due to severe cognitive impairment. The MDS indicated that she was totally dependent on two…

    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 · D2022-12-19 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 79 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to ensure foot pedals were provided for Resident (R) 30's wheelchair to prevent his feet from dragging on the floor. This deficient practice placed R30 at risk for accidents and injuries. Findings included: - R30's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of muscle weakness, dementia (progressive mental disorder characterized by failing memory, confusion), and hypertension (elevated blood pressure). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented that R30 required extensive assistance of two staff members for activities of daily living (ADLs). The Quarterly MDS dated 11/10/22 documented R30 had severely impaired cognition. The MDS documented that R30 required extensive assistance of two staff…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-19 · 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 79 residents. The sample included 18 residents with 18 residents reviewed for care plan revisions. Base on observation, record review, and interviews, the facility failed to revise care plan interventions related to Resident (R)26's ongoing exit seeking behaviors and need for a Wanderguard bracelet (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort). This deficient practice placed R26 at risk for wandering related accidents and unmet care needs. Findings Included: - The Medical Diagnosis section within R26's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), insomnia (inability to sleep), benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). R26's admission…

    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 · D2022-12-19 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    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 79 residents. The sample included 18 residents with one reviewed for activities. Based on observations, interviews, record review, and policy review, the facility failed to ensure Resident (R) 30 was provided with a meaningful activity program to address his assessed needs. This placed him at risk for impaired psychosocial wellbeing including boredom, agitation and restlessness. Findings Included: - R30's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of muscle weakness, dementia (progressive mental disorder characterized by failing memory, confusion), and hypertension (elevated blood pressure). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented that R30 required extensive assistance of two staff members for activities of daily living (ADLs). The Quarterly MDS dated 11/10/22 documented R30 had severely impaired cognition.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-19 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 79 residents. The sample included 18 residents with two residents reviewed for limited range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). Based on observation, record review, and interviews, the facility failed to provide the necessary services for Resident (R) 6's multiple contractures (abnormal fixation of a joint) to prevent further loss of ROM and mobility, which placed R6 at risk of a possible decline in independence, skin breakdown and impaired psychosocial wellbeing. Findings included: - R6's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of cerebrovascular accident (CVA-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 artery to the brain), contracture of left hand, right knee, left knee, left wrist, left elbow and left shoulder. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-19 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 79 residents. The sample included 18 residents with four residents reviewed for accidents. Base on observation, record review, and interviews, the facility failed utilize Resident (R)5's wheelchair seatbelt resulting in a minor-injury fall. The facility additionally failed to monitor, check placement, or function of R26's WanderGuard bracelet (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort). This deficient practice placed both residents at risk for preventable accidents and related injuries. Findings Included: - The Medical Diagnosis section within R5's Electronic Medical Records (EMR) included diagnoses of cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth), epilepsy (brain disorder characterized by repeated seizures), intellectual disabilities, muscle weakness, Lennox-Gastuat syndrome (severe condition with…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-19 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 79 residents. The sample included 18 residents with one resident reviewed for dementia care services. Based on observation, record review, and interviews, the facility failed to provide dementia (progressive mental disorder characterized by failing memory, confusion) care and treatment for Resident (R)76, a cognitively impaired resident displaying dementia related symptoms. This deficient practice placed R76 at risk for impaired ability to achieve and/or maintain her highest practicable level of physical and emotional wellbeing. Finding Included: - The Medical Diagnosis section within R76's Electronic Medical Records (EMR) included diagnoses of dysphagia (swallowing difficulty), difficulty walking, hearing loss, atrial fibrillation (rapid, irregular heartbeat), cognitive communication deficit, and a history of malignant neoplasm (cancer). R76's Quarterly Minimum Data Set (MDS) dated 11/24/22 noted a Brief Interview for Mental Status (BIMS) score of eight indicating moderate cognitive impairment. The MDS indicated that R76 exhibited verbal…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-19 · 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 79 residents. The sample included 18 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified an inappropriate indication for use an antipsychotic (medication used to treat severe mental conditions) medication for Resident (R) 30 who had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). This deficient practice had the potential of unnecessary psychotropic medication administration, thus leading to possible harmful potential side effects. Findings included: - R30's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of muscle weakness, dementia, and hypertension (elevated blood pressure). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented that R30…

    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 before2022-12-19 · 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 79 residents. The sample included 18 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure AN appropriate indication for use of an antipsychotic (medication used to treat severe mental conditions) medication for Resident (R) 30 who had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). This deficient practice had the potential of unnecessary psychotropic medication administration, thus leading to possible harmful potential side effects. Findings included: - R30's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of muscle weakness, dementia, and hypertension (elevated blood pressure). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented that R30 required extensive assistance of two…

    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 · D2022-12-19 · tag F0761 — failed to label and store drugs safely — isolated
    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 identified a census of 79 residents and 10 medication carts. Based on observation, record review, and interview, the facility failed to discard an outdated individual insulin (a hormone which regulates blood sugar) pen in one of the medication carts. This deficient practice left the affected resident at risk for adverse consequences or less effective medication treatment. Findings included: - On 12/14/22 at 10:58 AM Licensed Nurse (LN) I unlocked the nurse's medication cart for E Court. Upon observation of the top-drawer contents it was noted that one Novolog aspart insulin pen (a short-acting insulin that lasted four to six hours) was opened and dated 10/29/22. According to the Health Direct Pharmacy Services Novolog aspart insulin expired 28 days after opening. On 12/14/22 at 10:58 AM LN I stated that the nurse should check medications in the medication cart daily for expired medications including insulin. LN I stated she had noted that the Novolog apart insulin pen was outdated and had called the pharmacy to send more. LN I discarded the outdated insulin pen. On…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2021-05-13 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 74 residents. Based on observation, interview and record review, the facility failed to ensure sanitary laundering of linen soiled with blood to prevent cross contamination with blood borne pathogens. Findings included: - Observation, on /05/12/21 at 08:59 AM, revealed Laundry staff U, processing laundry. Laundry Staff U stated the current load in the washer, contained yellow bag (contaminated) personal clothing and linens. Laundry staff U stated she chose the personal cycle to wash this load. Staff U stated the linen contained soiling with blood and thought the personal cycle dispensed enough bleach to remove the blood stains but preserved the colors of the personal laundry. Laundry staff U stated she did not have a manufacturers formula chart to determine which setting for soiled laundry, colors, delicate etc., but there were several cycles to choose from when she set the load function on the machine. Observation revealed, after the cycle completed, Laundry Staff U, removed the clothing and linen (towels, sheets, and blankets) and proceeded to…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-05-13 · tag F0657 — failed to keep the care plan current — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 74 residents with 22 residents included in the sample. Based on observation, record review and interview, the facility failed to review and revise the care plans for four of the residents sampled, including Resident (R) 2, R33, and R47 regarding timely interventions after falls to prevent further falls, and timely interventions to prevent further skin tears on the arms of one sampled resident R51. Findings included: - The Physician Order Sheet (POS), dated 04/06/21, documented Resident (R)2 had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. He required extensive assistance of two staff for bed mobility, transfers and toilet use. His balance was not steady, and he was only able to stabilize with staff assistance. He used a walker and a…

    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 · D2021-05-13 · 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 reported a census of 74 residents with 22 residents sampled, including six residents reviewed for nutrition. Based on observation, interview, and record review, the facility failed to identify, plan, and implement timely interventions to maintain nutritional status for one of the six residents reviewed, Resident (R) 172. Findings included: - The Physician Order Sheet (POS), dated 05/13/21, documented Resident (R)172 had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion), irritable bowel syndrome (IBS- abnormally increased motility of the small and large intestines), anxiety, fractures and other multiple trauma. The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She was independent with eating and only required setup help. She had no swallowing or dental issues, and no weight loss or gain. She was 60 inches tall and her weight was 114 pounds…

    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

“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

$13,397 in federal fines across 1 penalty.

  • $13,397 — penalty dated 2024-05-06

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

Part of a chain

This home belongs to RECOVER-CARE HEALTHCARE — 27 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.4+0.6 vs chain
Health inspection 3 of 52.5+0.5 vs chain
Staffing 2 of 52.4-0.4 vs chain
Quality measures 2 of 53.1-1.1 vs chain
The other 26 homes this chain runs (chain average 2.4★, per CMS)
1 of 5Kenwood View Healthcare And Rehabilitation CenterSalina, KS 1 of 5Meadowbrook Rehabilitation HospitalGardner, KS 1 of 5Parkview Health And Rehabilitation CenterOsborne, KS 1 of 5Plaza West Healthcare And RehabTopeka, KS 1 of 5Richmond Healthcare & Rehab CenterRichmond, KS 1 of 5Rossville Healthcare And Rehabilitation CenterRossville, KS 1 of 5Shawnee Gardens Healthcare & Rehab CenterShawnee, KS 1 of 5The Gardens At AldersgateTopeka, KS 1 of 5Via Christi Village Hays Ks LLCHays, KS 2 of 5Belleville Healthcare And Rehabilitation CenterBelleville, KS 2 of 5Brighton Place WestTopeka, KS 2 of 5Cambridge PlaceMarysville, KS 2 of 5Hilltop Lodge Health And Rehabilitation CenterBeloit, KS 2 of 5Hope Springs Care CenterMontrose, CO 2 of 5Merriam Gardens Healthcare & Rehabilitation CenterMerriam, KS 3 of 5Gem City Healthcare And Rehabilitation CenterDayton, OH 3 of 5Heritage Gardens Health And Rehabilitation CenterOskaloosa, KS 3 of 5Louisburg Healthcare And Rehabilitation CenterLouisburg, KS 3 of 5Spring View Manor Healthcare And RehabilitationConway Springs, KS 3 of 5Wathena Healthcare & Rehabilitation CenterWathena, KS 4 of 5Flint Hills Care And Rehabilitation CenterEmporia, KS 4 of 5Parkview Heights Nursing And Rehabilitation CenterGarnett, KS 4 of 5Sandpiper Healthcare & Rehabilitation CenterWichita, KS 5 of 5Baldwin Healthcare & Rehab Center, LLCBaldwin City, KS 5 of 5Minneapolis Healthcare And Rehabilitation CenterMinneapolis, KS 5 of 5Pinnacle Park Nursing & Rehab CenterSalina, KS

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
HEARTLAND RECOVERY LLCOrganizationDIRECT OWNERSHIP INTERESTsince 07/01/2025
BHNV LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 02/28/2025
KAMNA HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 07/01/2025
KANSAS HEALTHCARE HOLDINGS 200 LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 07/01/2025
MAD FAMILY HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 07/01/2025
NATR TRUSTOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 07/01/2025
RARMNA HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 07/01/2025
RATR TRUSTOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 07/01/2025
RECOVER-CARE SNF HOLDINGS 200 LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 07/01/2025
RNR HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 07/01/2025
WETR TRUSTOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 07/01/2025
ZM SNF HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 07/01/2025
HALBERSTAM, MIRIAMIndividualINDIRECT OWNERSHIP INTERESTsince 07/01/2025
HALBERSTAM, MOSHEIndividualINDIRECT OWNERSHIP INTERESTsince 07/01/2025
MARGULIES, ZISHAIndividualCORPORATE DIRECTORsince 07/01/2025
MRC SNF MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/26/2025
BAILEY, AMYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2025
GARNER, MINDIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/26/2025
KFAR HABOR LLCOrganizationADP OF THE SNFsince 06/09/2025

CMS files one row per role, so the 29 rows in the source record cover these 19 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.

14 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.

$10.4M
Net patient revenuemost recent cost report
-7.5%
Operating marginrevenue minus expenses
$1.8M
Related-party expense16% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 6%Other / private 94%

This home reported $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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

$286per resident / day
operating cost
$8,702per month
≈ monthly operating cost
$266per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in KS

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Kansas Medicaid page.

Typical monthly cost in Kansas
$8,669/mo
Nursing home (semi-private)
$9,064/mo
Nursing home (private)
$5,975/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175465. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-21, 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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