No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Wathena Healthcare & Rehabilitation Center

2112 Highway 36, Wathena, KS 66090 · For profit - Limited Liability company · 60 certified beds · (785) 989-3141 Medicare & Medicaid certified

Call the home — (785) 989-3141 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 26 lower-level deficiencies on record (see below)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • about 20% of its spending goes to commonly-owned related companies
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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

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

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

Location & what’s nearby

Urgent care / clinic
1515 Saint Joseph Ave · (816) 233-3338 · Call to confirm hours
Pharmacy
1517 Saint Joseph Ave · (816) 279-2590 · Call to confirm hours
Grocery
Trex Mart4.8 mi
211 Roseport Rd · (913) 365-5622 · Call to confirm hours
Park
501 N 9th St · Typically dawn to dusk
Place of worship
2108 Highway 36 · (785) 989-3348

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 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 3 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 1 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 increased20.7%17.9%15.4%worse
Long-stay residents who lose too much weight9.0%4.9%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%1.6%0.9%better
Long-stay residents with a urinary tract infection0.8%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 whose ability to walk worsened15.4%16.2%16.1%typical
Long-stay residents on antianxiety or hypnotic medication11.0%23.2%18.9%better
Long-stay residents given the seasonal flu vaccine94.3%95.5%95.3%typical
Long-stay residents with pressure ulcers6.0%4.4%4.7%worse
Long-stay residents with worsening bladder/bowel control28.5%22.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table11.1%18.1%17.1%better
Short-stay residents who newly got an antipsychotic medication2.6%1.9%1.4%worse
Short-stay residents given the seasonal flu vaccine36.8%73.8%79.4%worse
Short-stay residents rehospitalized after admission21.4%22.4%22.6%typical
Short-stay residents with an outpatient ER visit6.8%11.5%12.0%better
Long-stay hospitalizations per 1,000 resident days2.441.801.67worse
Long-stay outpatient ER visits per 1,000 resident days1.002.131.80better

* 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.

47.2% 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 54 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

47.2%U.S. median 51.5%
Got home and stayed home
10.9%U.S. median 10.7%
Went back to hospital
48.3%U.S. median 56.6%
Met the expected recovery
0.45U.S. median 0.31
Therapy hours / resident / day
0.25hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Met the expected recovery: 48.3% 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 29 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 0.45 therapist hours per resident per day in 2026Q1 — more than 75% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% 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 SNF47.2%CMS range 37.5–60.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.9%CMS range 7.7–15.510.7%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 discharge48.3%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 discharge41.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge51.7%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 setting95.0%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 stay0.0%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 worsened2.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.8%CMS range 4.8–14.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.301.02Oct 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

0.55
RN hours/ resident / day
0.87
LPN hours/ resident / day
2.03
Aide hours/ resident / day
3.45
Total nurse hours/ resident / day
0.50
RN hoursweekends
36.1%
Total nursing turnover
57.1%
RN turnover

How full it usually is: this home is certified for 60 beds and averages 36.1 residents a day — about 60% occupied, or roughly 24 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.45 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.555 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.03 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.11 hrs/resident/day on weekends vs 3.59 on weekdays — 13% thinner on weekends. RN hours go from 0.58 to 0.50 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 36% is about the same as the national median of 45%.

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

Inspection trend

6
deficiencies at the latest standard inspection (2024-09-25)
13
at the previous standard inspection (2023-04-26)

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

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

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

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.

26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · F2024-09-25 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 39 residents. The facility had one main kitchen and one dining area. Based on record review and interview, the facility failed to ensure the director of food and nutrition services had the required qualifications of a certified dietary manager (CDM). This placed the residents at risk for unmet dietary and nutritional needs. Findings included: - On 09/23/24 at 04:27 PM, Dietary BB stated the registered dietitian visited every two weeks. Dietary BB stated she still needed to pass the test to become a CDM because she took it once and did not pass but had to wait 90 days to try again. On 09/24/24 at 11:05 AM, Dietary BB stated she had been the dietary manager for four years and it had taken a couple of years to get the CDM education completed because of the pandemic. On 09/25/24 at 01:36 PM, Administrative Staff A stated Dietary BB had taken the state test to become a CDM but did not pass. He stated the current plan included her taking the test again but they might have to see if another dietary member wanted to become certified or find a CDM if it…

    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 · Fcited before2024-09-25 · 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 39 residents. The facility had one main kitchen. Based on observations, record review, and interviews, the facility failed to ensure the big cooler maintained an appropriate temperature range, failed to ensure staff consistently monitored cooler and freezer temperatures, and failed to ensure staff consistently monitored the dishwasher temperatures and chemical sanitation levels. The facility further failed to ensure adequate hand hygiene during meal service. This deficient practice placed residents at risk for food-borne illnesses. Findings included: - On the initial tour of the kitchen on 09/23/24 at 08:11 AM, the big cooler had a temperature of 46 degrees Fahrenheit. The big cooler contained produce, cheese, condiment containers, eggs, sour cream, cottage cheese, and other food items. On 09/24/24 at 07:48 AM, Administrative Nurse D delivered a bowl to a resident in the dining room and then helped a male resident with a clothing protector. She then asked Resident (R) 3 if he wanted a clothing protector and helped him put it on. The kitchen 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-09-25 · 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 39 residents. The sample included 12 residents. Based on interviews and record review, 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 39 residents residing in the facility. Findings Included: - An inspection of the Facility Assessment dated 08/01/24 provided by the facility revealed the following: The assessment failed to identify the specific staffing levels needed for each unit and identify the number of Registered Nurses (RN), Licensed Nurses (LPN), Certified Medication Aides (CMA), and Certified Nurse Aides (CNA) needed for each unit, patient acuity, and census. The assessment lacked the staffing levels required for each shift. The assessment lacked an informed contingency plan for events that do not require activation of the facility's emergency plan but have the potential to impact resident care. The assessment lacked a contingency plan to maximize recruitment and retention 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-09-25 · 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 identified a census of 39 residents. Based on observations, record review, and interviews, the facility failed to ensure staff followed Enhanced barrier precautions (EBP), and failed to ensure staff performed appropriate hand hygiene during medication pass. The facility further failed to assess, identify risks, and create a plan to address the risk for Legionella disease (Legionella is a bacterium that can cause pneumonia in vulnerable populations) or other opportunistic waterborne pathogens. This deficient practice placed the residents at risk for infectious diseases. Findings included: - On 09/24/24 at 08:58 AM, Resident (R)8 had an isolation basket with isolation supplies on the back of her room door without a sign denoting the type of isolation or PPE required. Licensed Nurse (LN) G performed wound care on R8 without wearing an isolation gown. On 09/24/24 at 09:20 AM, R16 had an isolation basket with isolation supplies on the back of his room door without a sign denoting the type of isolation or PPE required. Certified Nurse Aide (CNA) P performed catheter 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-09-25 · tag F0945 — failed to train staff on abuse prevention — widespread
    Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 39 residents. Based on record review and interviews, the facility failed to ensure agency direct care staff had received the required infection control training. This placed the residents at risk for impaired care and decreased quality of life. Finding included: - On 07/10/24 at 10:40 AM a review of the training for agency Certified Nurses Aid (CNA) M, and CNA N and CNA O revealed the following: CNA M's facility-provided credentialling file lacked evidence training was completed for infection control training. CNA N's facility-provided credentialling file lacked evidence training was completed for infection control training. CNA O's facility-provided credentialling file lacked evidence training was completed for infection control training. On 09/25/24 at 01:48 PM Administrative Nurse D stated the facility did go over resident rights and Abuse, Neglect, and Exploitation training with the agency staff. Administrative Nurse D stated she would begin doing the communication, infection control, and the other required nurse aide training upon hire 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 · D2024-09-25 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 39 residents. The sample included 12 residents with three residents reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide a bed hold policy notice to Resident (R) 4 and R20 or their representatives when they transferred to the hospital. This deficient practice had the risk of impaired ability to return to the facility and to the previous room for R4 and R20. Findings included: - R4 admitted to the facility on [DATE], discharged to the hospital on [DATE], readmitted to the facility on [DATE], discharged to the hospital on [DATE], and readmitted to the facility on [DATE]. R4's Electronic Medical Record (EMR) documented diagnoses of nausea, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and cough. The Annual Minimum Data Set (MDS) dated 01/15/24, documented that R4 had a Brief Interview for Mental…

    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 · E2023-04-26 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 41 residents. The sample include 13 residents. Based on observation, record review, and interviews, the facility failed to provide activities for the residents during weekends. This deficient practice placed the affected residents at risk for decreased psychosocial wellbeing. Findings Included: - A review of the Activity Calendar for April 2023 indicated Saturday activities listed were Resident Choice and Movies with a resident shopping trip on the 04/15/23. A review of Sunday activities revealed only Church and Leisure for the month. A review of January 2023, February 2023, and March 2023 calendars revealed the same activities pattern with little facility led groups. On 04/24/23 at 10:33AM, Resident Council members reported the facility used to have a volunteer come in on weekends to provide games and activities, but the volunteer stopped coming. The council reported the Activities Coordinator tried to come in some weekends but many weekends, the residents do not have activities other than television. On 04/26/23 at 02:45PM Activities Coordinator…

    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 · E2023-04-26 · 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 41 resident. Based on observations, record review, and interviews, the facility failed to ensure safe/secure storage for one of the two medication carts in the facility. This deficient practice placed the residents at risk for accidental medication ingestion or diversion. Findings Included: - On 04/25/2023 at 08:53AM the medication storage (treatment) cart was left unsecured in the 100's hallway. An inspection of the cart revealed Resident (R)12's Novolog (short-acting hormone which regulates blood sugar) Kwik pen injector medication and Lantus (long-acting hormone which regulates blood sugar) kwikpen injector medication, R24's prochlorperazine medication (used to treat migraines and nausea), R22's cyanocobalamin (vitamin b12 supplements) medication, and R6's Tylenol medication. The cart was secured by Licensed Nurse (LN) G at 09:00AM. LN G reported the nurses should ensure the carts are locked when not in use or unattended. On 04/26/23 at 03:35PM Administrative Nurse D stated staff should be locking the cart any time they are not using them. She…

    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 · D2023-04-26 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 41 residents. The sample included 13 residents with two residents reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 19 was treated with dignity. This deficient practice placed R19 at risk for negative psychosocial outcomes and decreased autonomy and dignity. Findings included: - R19's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia without behaviors (progressive mental disorder characterized by failing memory, confusion), major depressive disorder (major mood disorder), and posttraumatic stress disorder (PTSD- psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score…

    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 · D2023-04-26 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 41 residents. The sample included 13 residents. Based on observation, record review, and interviews, the facility failed to notify the physician of Resident (R) 96's refusal to be weighed for weight loss monitoring. This deficient practice placed R96 at risk of miscommunication between facility and physician and a possible missed opportunity for healthcare services related to continued weight loss. Findings included: - R96's Eelectronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia with behaviors (progressive mental disorder characterized by failing memory, confusion), mild cognitive impairment, and psychosis (any major mental disorder characterized by a gross impairment testing). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 99 and a staff interview documented R96 had severely impaired cognition. The MDS documented that R96 required extensive assistance of two staff members 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · D2023-04-26 · 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 41 residents with 13 residents included in the sample. The facility identified two residents who discharged from Medicare Part A services. Based on interview and record review the facility failed to issue CMS (Center for Medicare/Medicaid Services) Skilled Nursing Facility Advance Beneficiary Notification (SNF ABN) form 10055 (the form used to notify Medicare A participants of potential financial liability when a Medicare Part A episode ends) with the required information for Resident (R) 34 and R247. This failure placed the residents at risk for decreased autonomy and impaired right to appeal. Findings included: - Review of R34's Electronic Medical Record (EMR) documented the Medicare Part A episode began on 09/14/22 and ended on 12/16/22. R34 remained in the facility for custodial care. The facility-issued SNF ABN 10055 lacked an estimated cost for continued services. Review of R247's Electronic Medical Record (EMR) documented the Medicare Part A episode began on 08/29/22 and ended on 11/11/22. R247 remained in the facility for custodial 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 · D2023-04-26 · 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 identified a census of 41 residents. The sample included 13 residents. Based on observation, record review, and interviews, the facility failed to update the comprehensive care plan with current interventions related to a significant weight loss for Resident (R) 96. This deficient practice placed R96 at increased risk for continued weight loss due to uncommunicated care needs/goals. Findings included: - R96's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia with behaviors (progressive mental disorder characterized by failing memory, confusion), mild cognitive impairment, and psychosis (any major mental disorder characterized by a gross impairment testing). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 99 and a staff interview documented R96 had severely impaired cognition. The MDS documented that R96 required extensive assistance of two staff members for activities of daily living (ADLs). 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-26 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 41 residents. The sample included 13 residents. Based on observation, record review, and interviews, the facility failed to ensure staff implemented appropriate infection control practices during wound care for Resident (R) 246, who had a history of cellulitis (skin infection caused by bacteria characterized by heat, redness and swelling). This deficient practice placed R246 at risk of wound worsening and complications related to infections. Findings included: - R246's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness) and obesity (a condition of being grossly overweight). The admission Minimum Data Set (MDS) was in progress and not completed. R246's Care Area Assessment (CAA) was in progress. R246's Care Plan dated 04/11/23 documented for staff to apply peri-guard (petrolatum-based barrier ointment) to buttocks every shift related to moisture-associated skin damage (MASD-inflammation or skin erosion…

    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 · D2023-04-26 · 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 had a census of 39 residents. The sample included 13 residents with five residents reviewed for accidents. Based on observation, record review and interview the facility failed to secure rooms containing hazardous materials out of reach of the residents and ensure the proper usage of wheelchair foot pedals during transport for Residents (R)10 and R11. The facility additionally failed to implement individualized toileting interventions in response to repeated falls for R35. This deficient practice placed the residents at risk for preventable injuries and accidents. Findings Included: - On 04/24/23 at 07:40AM an inspection of the facility's Supplemental Oxygen storage room revealed the door securing the room was unlocked and accessible to the residents. The room contained 48 oxygen cannister stored in racks and three small cylinder cannister left unsecured on a shelf above the larger tank rack. At 07:45AM Licensed Nurse (LN) G secured the room and reported it should always be locked. On 04/24/23 at…

    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 · D2023-04-26 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 41 residents. The sample included 13 residents with three reviewed for bowel and bladder management. Based on observation, record review, and interviews, the facility failed to implement individualized toileting interventions related to bowel and bladder incontinence for Residents (R)12, and R35. This deficient practice placed the residents at risk for complications related to incontinence. Findings Included: -The Medical Diagnosis section within R12's Electronic Medical Records (EMR) included diagnoses of urinary incontinence (involuntary passage of urine occurring soon after a strong sense of urgency to void), Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), muscle spasms, history of hip fracture (broken bone), major depressive disorder (major mood disorder), morbid obesity (severely overweight), and type two diabetes mellitus (when the body…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-26 · 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 41 residents. The sample included 13 residents with five reviewed for nutrition. Based on observation, record review, and interviews, the facility failed to monitor weekly weights and ensure supplements for Resident (R) 96 who had a history of weight loss and failed to monitor the effectiveness of interventions for R35, who continued to lose weight. This deficient practice placed the residents at risk for continued unintended weight loss and malnutrition. Findings included: - R96's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia with behaviors (progressive mental disorder characterized by failing memory, confusion), mild cognitive impairment, and psychosis (any major mental disorder characterized by a gross impairment testing). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 99 and a staff interview documented R96 had severely impaired cognition. The MDS documented that R96…

    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 · D2023-04-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 41 residents. The sample included 13 residents with two reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to store Resident (R)12 and R26's supplemental oxygen equipment (masks and tubing) in a sanitary manner. This deficient practice placed both residents at risk for complications related to respiratory care and infections. Findings Included: - The Medical Diagnosis section within R12's Electronic Medical Records (EMR) included diagnoses of urinary incontinence (involuntary passage of urine occurring soon after a strong sense of urgency to void), Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), muscle spasms, history of hip fracture (broken bone), major depressive disorder (major mood disorder), morbid obesity (severely overweight), and type two diabetes mellitus (when the body cannot use…

    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 before2023-04-26 · 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 41 residents. The sample included 13 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to notify the medical provider of Resident (R)11's repeated refusals for his lab draws related to his valproic acid levels (also known as Depakote- medication used to treat seizure disorders). This deficient practice placed R11 at risk for unnecessary medicals and adverse medication effects (unintended harmful reaction to a drug administered at normal dosage). Findings Included: - The Medical Diagnosis section within R11's Electronic Medical Records (EMR) included diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), dementia (progressive mental disorder characterized by failing memory, confusion), seizures (violent involuntary series of contractions of a group 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 · Ecited before2021-10-20 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 34 residents. The facility had one main kitchen. Based on observations, record reviews, and interviews, the facility failed to ensure that food items were properly stored in a safe and sanitary manner after the original sealed package had been opened, and the food item was not placed in a sealed container/storage bag with the proper labeling and date. This deficient practice had the risk to spread food-borne illness to residents and staff. Findings included: - The initial tour of the facility kitchen on 10/18/21 at 07:19 AM revealed the following: in dry storage area there was an opened bag of dried mashed potato chips that was not in a sealed bag, was not labeled or dated when opened. There was a sealed plastic storage bag with flour tortillas inside, the bag was not dated or labeled; there was a sealed plastic storage bag in the refrigerator that contained half of a tomato, no label or date on the bag; the freezer had an opened box of grilled chicken breast fillets, original bag in box was opened to air, remaining chicken breasts had not been…

    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 · Ecited before2021-10-20 · 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 34 residents. The sample included 12 residents; three residents on 14-day isolation (transmission-based precautions [infection control precautions in health care] taken after admission to prevent potential spread of COVID-19 [an acute respiratory illness in humans caused by coronavirus, capable of producing severe symptoms and in some cases death]) on the 200 hall. Based on observations, record reviews, and interviews, the facility failed to ensure appropriate hand hygiene with meal tray pass, appropriate personal protective equipment (PPE) usage in isolation room and failed to ensure prevention of cross-contamination during cleaning of an isolation room. This deficient practice increased the risk of infection and illness to the affected residents. Findings included: - On 10/18/21 at 08:30 AM, Resident (R) 25, R132, and R183 were on 14-day isolation after being admitted due to being unvaccinated against COVID-19. There were PPE storage bins outside their rooms but there were no signs on their doors or doorframes that instructed staff what PPE was…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-10-20 · 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

    The facility identified a census of 34 residents. The sample included 12 residents; one resident sampled for hospitalization. Based on observations, record reviews, and interviews, the facility failed to notify the state ombudsman of transfers and failed to provide a written notification of transfers to Resident (R) 3 or to his 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: - R3 was sent to the hospital emergency room (ER) on the following dates: 02/24/21, 02/27/21, 03/09/21, 03/29/21, 04/30/21, 05/01/21, 07/29/21, 09/23/21, and 10/12/21. The Diagnoses tab of R3's Electronic Medical Record (EMR) documented diagnoses of neuromuscular dysfunction of bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system) and urinary tract infection. The admission Minimum Data…

    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 · D2021-10-20 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 41 residents. The sample included 12 residents. Based on observations, record reviews, and interviews, the facility failed to ensure accurate assessment and documentation on the Minimum Data Set (MDS) for documentation of anticoagulant (medication used to prevent blood from thickening or clotting) use for Resident (R) 23. This deficient practice had the risk for miscommunication related to anticoagulation status. Findings included: - The Diagnoses tab of R23's Electronic Medical Record (EMR) documented diagnoses of peripheral vascular disease (abnormal condition affecting the blood vessels), coronary angioplasty status (procedure used to widen blocked or narrowed heart arteries), essential hypertension (high blood pressure), and atherosclerotic heart disease (buildup of fats, cholesterol, and other substances in and on artery walls). The admission MDS dated 09/27/21, documented R23 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R23 required limited physical assistance with one staff member for bed…

    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 · D2021-10-20 · 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 identified a census of 34 residents. The sample included 12 residents. Based on record reviews and interviews, the facility failed to ensure availability of physician ordered pain medication for Resident (R) 182. This deficient practice had the risk for unwarranted physical pain and complications. Findings included: - R182 admitted to facility on 10/01/21 and discharged to hospital on [DATE]. The Diagnoses tab of R182's Electronic Medical Record (EMR) documented diagnoses of low back pain, muscle weakness, and idiopathic peripheral autonomic neuropathy (condition of unknown cause that occurs when the nerves that control involuntary bodily functions are damaged). The admission Minimum Data Set (MDS) dated 10/08/21, documented R182 had a Brief Interview for Mental Status (BIMS) of 15 which indicated intact cognition. R182 received opioid (pain medication) seven days in the seven-day lookback period. The Pain Care Area Assessment (CAA) dated 10/08/21, documented R182's pain was addressed in 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-10-20 · 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 34 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 the Consultant Pharmacist (CP) identified and reported to facility isosorbide mononitrate (antihypertensive medication, used to treat hypertension- high blood pressure) given outside of parameters, lack of heart rate documentation for isosorbide mononitrate with set heart rate parameters, lack of blood pressure/heart rate parameters for metoprolol tartrate (antihypertensive medication) which was occasionally held for Resident (R) 23; failed to ensure the CP identified and reported metoprolol succinate (antihypertensive medication) was held without set parameters for R7; and failed to ensure the CP identified and reported lack of blood pressure/heart rate documentation for amlodipine (antihypertensive) with set parameters for R9. This deficient practice had the risk for unwarranted physical…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-10-20 · 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 34 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 isosorbide mononitrate (antihypertensive medication, used to treat hypertension- high blood pressure) was not given outside of parameters, failed to ensure heart rate documentation for isosorbide mononitrate with set heart rate parameters, failed to ensure blood pressure/heart rate parameters for metoprolol tartrate (antihypertensive medication) which was occasionally held for Resident (R) 23; failed to ensure metoprolol succinate (antihypertensive medication) had set blood pressure/heart rate parameters which was held without set ordered parameters and failed to obtain ordered laboratory services for R7; and failed to blood pressure/heart rate documentation for amlodipine (antihypertensive) with set parameters for R9. This deficient practice had the risk for unwarranted physical…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-04-26 · tag F0576 — widespread
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 41 residents. The sample include 13 residents. Based on observation, record review, and interviews, the facility failed to provide mail services on Saturdays. Findings Included: - On 04/24/23 at 10:31AM, Resident Council members reported that facility does not provide mail services for the residents on Saturdays. The council reported that most of the mail they received was on Monday due to no one passing it over the weekend. On 04/26/23 at 02:15PM Activities Coordinator (AC) Z reported that she was responsible for delivering the mail to the residents but does not work every weekend. She stated staff should have been providing the mail to the residents on weekend. She stated that the direct care staff should have pulled out greeting cards and presents for the residents and delivered it to them. She stated if staff was unable to pass the mail, she would deliver it on the following Monday. She stated the facility had volunteers to come in on weekends to assist but haven't the last few Saturdays. On 04/26/23 at 03:40PM Administrative Nurse D stated…

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

    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

No federal fines in the current CMS record.

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 3 of 52.4+0.6 vs chain
Quality measures 3 of 53.1-0.1 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 5Via Christi Village PittsburgPittsburg, 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
MRCMM LLCOrganizationDIRECT OWNERSHIP INTERESTsince 02/28/2025
MRC SNF MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/26/2025
GAUL, BRADLEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/28/2025
YOUNG, DAVIDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/26/2025
BK 5 HUD FACILITIES LLCOrganizationADP OF THE SNFsince 11/28/2025
KANSAS SNF HOLDINGS LLCOrganizationADP OF THE SNFsince 02/28/2025
MAD FAMILY HOLDINGS LLCOrganizationADP OF THE SNFsince 02/28/2025
NATR TRUSTOrganizationADP OF THE SNFsince 02/28/2025
RARMNA HOLDINGS LLCOrganizationADP OF THE SNFsince 02/28/2025
RATR TRUSTOrganizationADP OF THE SNFsince 02/28/2025
RNR HOLDINGS LLCOrganizationADP OF THE SNFsince 02/28/2025
WETR TRUSTOrganizationADP OF THE SNFsince 02/28/2025

CMS files one row per role, so the 15 rows in the source record cover these 12 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.

10 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.

$5.3M
Net patient revenuemost recent cost report
+13.7%
Operating marginrevenue minus expenses
$930K
Related-party expense20% of expenses
Who pays — share of resident-days
Medicaid 52%Medicare 18%Other / private 30%

This home reported $930K paid to related parties — landlords or management companies under common ownership — equal to about 20% 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.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$295per resident / day
operating cost
$8,967per month
≈ monthly operating cost
$342per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in KS

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175216. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-09-25, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

What to do next