Family Health & Rehabilitation Center
639 S Maize Court, Wichita, KS 67209 · For profit - Limited Liability company · 72 certified beds · (316) 425-5600 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- nursing-staff turnover (66%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 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 held steady at 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 20.9% | 17.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.8% | 4.9% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 2.2% | 1.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.2% | 2.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.3% | 6.5% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 8.8% | 4.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 27.2% | 16.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 13.4% | 23.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 94.2% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.6% | 4.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 20.7% | 22.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 3.8% | 18.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.0% | 1.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 88.1% | 73.8% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 25.0% | 22.4% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 11.8% | 11.5% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.25 | 1.80 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.40 | 2.13 | 1.80 | better |
‡ 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.
64.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 444 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 42.9% 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 205 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 0.65 therapist hours per resident per day in 2026Q1 — more than 90% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 19% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 64.8%CMS range 60.5–68.5 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.3%CMS range 9.4–14.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 42.9% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 33.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 37.6% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 99.3% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 95.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.2% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.1%CMS range 5.0–10.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.75 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 72 beds and averages 66.5 residents a day — about 92% occupied, or roughly 6 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 4.81 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.38 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.09 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.23 hrs/resident/day on weekends vs 5.04 on weekdays — 16% thinner on weekends. RN hours go from 0.43 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 66% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.
- Potential for harm · F2026-03-04 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 66 residents and four kitchens. Based on observation, record review, and interviews the facility failed to maintain a sanitary environment and store food adequately to prevent contamination. Findings included:- During the initial kitchen inspection on 03/02/26 at 07:35 AM, observation in the food storage room on main hall revealed several cases of water stored directly on the floor. Dietary BB reported the emergency water had been on the floor for a few months.On 03/02/26 at 07:40 AM, observation in [NAME] House revealed the oven had a large amount of burnt dark residue on the bottom. The refrigerator had a staff member's lunch bag at the bottom. Dietary BB removed the lunch bag of the staff member and reported it should be stored in the employee refrigerator. On 03/02/26 at 07:51 AM, the [NAME] and [NAME] House refrigerator had an undated container of cut up apples with cinnamon and an undated bag of hash browns. The freezer had an undated bag of frozen biscuits. Dietary CC…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-04 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 66 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 12 had been assessed for the ability to safely self-administer his physician-ordered Fluticasone propionate nasal spray (a corticosteroid used to relieve allergy and nasal inflammation symptoms).Findings included:- R12's Electronic Medical Record (EMR) documented diagnoses of allergic rhinitis, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and unspecified dementia (progressive mental disorder characterized by failing memory, confusion).R12's Annual Minimum Data Set (MDS) dated 10/06/25 documented he had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. R12 used a wheelchair to assist with mobility and had no impairment in upper or lower extremities.R12's Quarter MDS dated 01/06/26 documented a BIMS score of 13, which indicated intact cognition. R12 used a walker or wheelchair to assist with mobility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-04 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 66. The sample included 18 residents. Based on record review and interviews, the facility failed to develop a comprehensive care plan for Resident (R) 65.Findings included:-R65's Electronic Medical Record (EMR) recorded diagnoses of irritable bowel syndrome, hypertension (high blood pressure), chronic respiratory failure, and urine retention.R65's admission Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS noted R65 was dependent upon staff assistance for toileting, dressing, and transfers. She had one non-injury fall.R65'S 12/18/25 Falls Care Area Assessment (CAA) triggered secondary to impaired balance with transitions and transfers and her need for assistance with activities of daily living. The CAA noted contributing factors included restricted mobility, medication usage, a need for assistance with transfers and a urinary catheter (tube inserted into the bladder to drain urine).…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-04 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 66. The sample included 18 residents. Based on observation, interviews, and record review, the facility failed to ensure Resident (R) 39 received the necessary staff assistance with oral hygiene.Findings included:- R39's Electronic Medical Record (EMR) recorded a diagnosis of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord). R39's 01/21/26 Annual Minimum Data Set (MDS) documented R39 had a Brief Interview for Mental Status (BISM) score of five, which indicated severe cognitive impairment. The MDS noted R39 was dependent upon staff assistance for oral hygiene.R39's Care Plan recorded interventions dated 12/31/25, which directed staff that R39 required supervision and partial/moderate assistance with eating. He required moderate assistance for oral hygiene tasks and staff should encourage and/or assist him with oral care in the morning and evening. R39's Orders noted an order dated 02/20/25 for staff to offer to brush R39's teeth twice daily (every shift). The consultant dentist's visit summary dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-04 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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
The facility identified a census of 66. The sample included 18 residents. Based on observation, record review and interviews, the facility failed to identify and implement interventions for Resident (R) 19 to address a nine-day period with no bowel movement.Findings included: -R19's Electronic Medical Record (EMR) recorded a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R19's 11/07/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. The MDS recorded R19 required maximal assistance with transfers and toileting hygiene and was frequently incontinent of bowel. R19's 11/17/25 Cognitive Loss/Dementia Care Area Assessment (CAA) documented R19 had a diagnosis of dementia with behaviors and had an order for medication. R19's Care Plan initiated on 11/07/25 and revised 12/29/25 noted R19 was at risk for altered nutrition and hydration related to dementia and chronic constipation. The plan noted R19 experiences pain related to osteoarthritis.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-04 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 66 residents. The sample included 18 residents, with one reviewed for tube feeding (administration of nutritionally balanced liquified foods or nutrients through a tube). Based on observation, record review, and interview, the facility failed to provide appropriate care and services for Resident (R) 4 when staff administered a medication and provided a tube feeding without using the physician's order for the amount of water before and after the procedure. Findings included: - R4's Electronic Medical Record (EMR) documented R4 had diagnoses of artificial openings of the gastrointestinal tract (surgical creation of an artificial opening into the stomach through the abdominal wall) R4's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had severely impaired cognition. The MDS documented R4 required total staff assistance with activities of daily living (ADLS), had no swallowing disorders, and received tube feedings. R4's Care Plan, revised on 02/17/26, documented…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-24 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 64 residents. The sample included 16 residents with one resident reviewed for abuse and neglect. Based on observation, record review, and interviews, the facility failed to protect Resident (R)25 and other vulnerable residents during the facility investigation after an abuse allegation. This placed R25 and the other residents under the care of Certified Nurse Aide (CNA) TT at risk for unidentified and ongoing abuse and /or neglect. Findings included: - The Medical Diagnosis section within R25's Electronic Medical Records (EMR) included diagnoses of acute kidney failure, lower extremity deep vein thrombosis (potentially life-threatening blood clot, usually in the legs), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (progressive mental disorder characterized by failing memory, and confusion). R25's admission Minimum Data Set (MDS) completed 01/25/24 noted a Brief Interview for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-24 · tag F0755 — failed to provide safe pharmacy services — patternProvide 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 64 residents. The facility had four medication carts. Based on observation, record review, and interview, the facility failed to ensure accurate reconciliation of controlled substances (substances that have an accepted medical use, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) was completed consistently. This placed residents at risk of medication misappropriation and diversion. Findings included: - On 04/22/24 at 09:18 AM, an observation of the medication cart on [NAME] House revealed the narcotic reconciliation sign-off sheets from 03/07/24 to 03/31/24 lacked a signature on 11 of 152 opportunities. On 04/22/24 at 09:18 AM, an observation of the medication cart on [NAME] House revealed the narcotic reconciliation sign-off sheets from 04/01/24 to 04/21/24 lacked a signature on 16 of 136 opportunities. On 04/22/24 at 11:26 AM Certified Medication Aide (CMA) S stated that the narcotic sign-on and off sheet…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-24 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 64 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to ensure the medication error rate did not exceed five percent (%) when staff failed to ensure Resident (R) 12 was administered her scheduled morning medications within the ordered timeframe. The facility failed to ensure the insulin (a hormone that lowers the level of glucose in the blood) pen and needle were appropriately primed before insulin administration to R161. This resulted in a medication error rate of 46.15%. Findings included: - On 04/22/24 at 12:20 PM Certified Medication Aide (CMA) WW washed her hands and returned to her medication cart to begin dispensing medications for R12. CMA WW pulled up R12's Medication Administration Record (MAR) and pulled R12's medication cards from the medication cart. CMA WW dispensed each medication (listed below) into a medication cup. CMA WW walked with the medication cup over to R12 who sat at the dining table eating lunch. R12 placed several of her medications in her hand at a time…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-04-24 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 64 residents. The facility had four medication storage refrigerators and four medication carts. Based on observation, record review, and interview, the facility failed to ensure safe and secure storage of medications and biologicals. This deficient practice created a risk of adverse side effects and ineffective medication administration. Findings included: - On 04/22/24 at 07:32 AM the medication refrigerator on the [NAME] House was left unlocked, and there was insulin (a hormone that lowers the level of glucose in the blood) for several residents unsecured. On 04/22/24 at 07:36 AM the medication refrigerator on [NAME] House was left unlocked and insulin for residents was unsecured. The inside of the refrigerator had a large amount of ice formation at the top. On 04/22/24 at 07:38 AM a medication cart on [NAME] House was left unlocked, and there was no nursing staff around the cart to monitor. The Nursing Facility Surveyor (NFS) stayed at the cart until Licensed Nurse (LN) H…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 14 citations
- Potential for harm · Ecited before2024-04-24 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 64 residents. The facility identified 25 residents on enhanced barrier precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employs targeted gown and glove use during high contact care). Based on observations, record review, and interviews, the facility failed to ensure consistent infection control standards were followed related to enhanced barrier precautions, storage of oxygen tubing, indwelling catheter (tube placed in the bladder to drain urine into a collection bag) care, laundry, and shared equipment. These deficient practices placed the residents at risk for complications related to infectious diseases. Findings Included- - On 04/22/24 at 08:00 AM an inspection of the identified EBP rooms revealed Resident (R)45 and R8's rooms lacked the required signage identifying the precautions needed to provide care. All 25 of the reviewed enhanced barrier precaution rooms stored the personal protective equipment (PPE)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-24 · tag F0947 — failed to train nurse aides adequately — patternEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 64 residents. The sample included 16 residents and three Certified Nurse Aides (CNAs) reviewed for 12 hours of required in-service training. Based on record review and interview, the facility failed to ensure three of the three CNA staff reviewed had the required 12 hours of in-service education which included the required dementia management training. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's staffing list revealed the following CNAs were employed with the facility for more than 12 months: CNA N, hired on 01/19/23 lacked evidence of dementia in-service training. CNA O, hired on 06/16/20 lacked evidence of dementia in-service training. CNA P, hired on 02/21/22 lacked evidence of dementia in-service training. A review of the Elopement and Missing Resident in-service training provided by the facility included one slide titled Characteristics of dementia and progressive dementia but lacked direction for staff on interventions and methods of approach for residents with dementia. A review 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.
- Potential for harm · D2024-04-24 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 64 residents. The sample included 16 residents with one resident reviewed for abuse and neglect. Based on observation, record review, and interviews, the facility failed to ensure staff reported an allegation of staff-to-resident abuse for Resident (R) 25 to the facility administrator immediately. The facility additionally failed to report R25's allegation of abuse to the State Agency (SA) as required. This placed R25 at risk for unidentified and ongoing abuse and /or neglect. Findings included: - The Medical Diagnosis section within R25's Electronic Medical Records (EMR) included diagnoses of acute kidney failure, lower extremity deep vein thrombosis (potentially life-threatening blood clot, usually in the legs), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (progressive mental disorder characterized by failing memory, and confusion). R25's admission Minimum Data Set (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.
- Potential for harm · D2024-04-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 64 residents. The sample included 16 residents. One resident was sampled for accidents and hazards. Based on observation, record review, and interviews, the facility failed to provide Resident (R) 42's fall interventions as directed by her care plan. This deficient practice placed R42 at risk of falls and related injuries. Findings included: - R42's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), epilepsy (brain disorder characterized by repeated seizures), a feeding tube (tube for introducing high-calorie fluids into the stomach), and transient ischemic attack (TIA- temporary episode of inadequate blood supply to the brain). The Quarterly Minimum Data Set (MDS) dated [DATE] documented that the facility was unable to conduct a Brief Interview of Mental Status (BIMS) score, R42's MDS documented the resident was rarely…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-24 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 64 residents. The sample included 16 residents with three reviewed for urinary catheters (a tube inserted into the bladder to drain urine) care. Based on observations, record reviews, and interviews, the facility failed to follow standards of practices related to indwelling catheter care for Resident (R)44. This deficient practice placed R44 at risk for catheter-related complications including urinary tract infections (UTI). Findings included: - The Medical Diagnosis section within R44's Electronic Medical Records (EMR) included diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis (weakness and paralysis on one side of the body), aphasia (a condition with disordered or absent language function), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). R44's Annual Minimum Data Set (MDS) completed 01/18/24…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-24 · tag F0698 — failed to provide proper dialysis care — isolatedProvide 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 identified a census of 64 residents. The sample included 16 residents with one resident reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to monitor Resident (R) 39's access site for complications at least daily and failed to obtain communication from the dialysis center related to R39's treatment. These deficient practices placed R39 at risk of potential adverse outcomes and physical complications related to dialysis. Findings included: - R39's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), end-stage renal disease (ESRD-a terminal disease of the kidneys), and dependence on dialysis. The Significant Change Minimum Data Set (MDS) dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-24 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 64 residents. The sample included 16 residents with five reviewed for unnecessary medications. Based on record review, observations, and interviews, the facility failed to follow the physician-ordered parameters related to Resident (R)17's as-needed (PRN) bumetanide (diuretic- medication to promote the formation and excretion of urine). This deficient practice placed R17 at increased risk for unnecessary medication and side effects. Findings included: - The Medical Diagnosis section within R17's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), left femur (large leg bone) fracture (bone break), and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). R17's Quarterly Minimum Data Set (MDS) completed 04/05/24 noted a Brief Interview for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-08-31 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility census totaled 69 residents. Based on observation, interview, and record review, the facility failed to ensure infection control practices when direct care staff did not change gloves when going from dirty to clean areas while providing care to Residents (R) 41 and R25. The facility also failed to ensure all staff members and visitors appropriately completed all COVID-19 (respiratory virus) screening, including temperature and signs/symptoms questionnaire. These failures had the ability to affect all 69 residents in the facility. Findings included: - The 08/29/22 through 08/31/22 COVID Screening Sheets were reviewed in each house for thorough completion. Of the 84 sheets reviewed, 42 of the sheets lacked documentation of a recorded temperature or completion of the COVID signs and symptoms questions. On 08/30/22 at 12:31 PM Certified Nurse Aide (CNA) D opened the house door for a visitor to enter the facility. CNA D did not ask the visitor to complete the screening, nor was screening offered or completed by the resident. Visitor entered the building without a mask 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.
- Potential for harm · D2022-08-31 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility census totaled 69 residents. Based on observation, interview, and record review, the facility failed to appropriately ensure all resident information was protected and kept private when a staff member left a computer screen unattended with resident information on the screen and visible. Findings included: - An observation on 08/25/22 at 08:08AM revealed the medication cart in House-3 was located outside of a resident's room with the computer screen open and contained resident information displaying upon the screen. The cart was left unattended by staff and observation revealed residents in the area, eating breakfast. Interview on 08/25/22 at 08:10AM with Certified Medication Aide (CMA) N revealed it was not normal to leave resident information on display while not using the computer. She stated she stepped away from the medication cart and computer screen to give a resident medication and did not lock the screen before walking away. CMA N stated best practice was to lock the computer screen prior to leaving the area to prevent the sharing of resident information.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-31 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 69 residents with 17 included in the sample including one for hospitalization. Based on observation, interview, and record review the facility failed to send a copy of the facility-initiated hospitalization transfer/discharge notice to the representative of the Office of the State Long-Term Care Ombudsman for Resident (R) 34. Findings included: - Review of R34's Minimum Data Set (MDS) tracking form documented the resident discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of R34 Medical Record lacked evidence of written notification of the facility-initiated hospitalization transfer/discharge notice to the representative of the Office of the State Long-Term Care Ombudsman. Observation of 08/29/22 at 07:04 AM revealed the resident sat at the dining room table, and staff were around preparing for the morning meal. On 08/30/22 review of the facility Ombudsman transfer/discharge notice list revealed it lacked notification of R34's hospitalization 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.
- Potential for harm · Dcited before2022-08-31 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 69 residents, with 17 sampled, including four for Activities of Daily Living (ADL). Based on observation, interview, and record review the facility failed to provide ADL assistance to include bathing services and shaving services to maintain good grooming for Residents (R) 9, who required limited assistance of one staff with bathing, and for R11, who required extensive assistance of one to two staff with bathing. Findings Included: - The 08/29/22 Electronic Health Record (EHR) documented R9 had the following diagnosis: hemiplegia (paralysis of one side of the body) of his right side. The 06/06/22 Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The 03/11/22 Cognition Loss/Dementia Care Area Assessment (CAA) documented R9 required assistance with ADLs due to the history of a traumatic brain injury (TBI, a head injury causing damage to the brain by external force or mechanism) and right sided hemiplegia. R9 required limited assistance of one staff with most ADLs, including…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-08-31 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 69 residents, with 17 included in the sample, and five reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure staff monitored the efficacy of insulin (hormone which regulates blood sugar) when staff failed to obtain physician ordered blood glucose (BG, blood sugar) values and failed to notify the physician of BG values outside of the ordered parameters for R31 and R50. Findings included: - R31's 07/21/22 Physician's Orders in the Electronic Medical Record (EMR) included a diagnosis of Diabetes Mellitus type 2 (DM2, when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The 07/27/22 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. R31 received insulin daily in the seven-day observation period. The 08/10/22 Care Plan instructed staff to administer diabetes medications as ordered and monitor/document R31 for side effects and effectiveness. Staff were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-08-31 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 census totaled 69 residents. Based on observation, interview and record review, the facility failed to appropriately ensure all medication carts remained locked when not in use by staff or when unattended. Findings included: - An observation on 08/25/22 at 08:08AM revealed the medication cart in House-3 located outside of a resident room, unlocked, and with the key in the lock. The cart was found unattended by staff, and residents were noted to be in the common area, eating breakfast. Interview on 08/25/22 at 08:10AM with Certified Medication Aide (CMA) N revealed the CMA working was the only staff member with keys to the medication cart for that shift. CMA N stated it was not normal to leave the keys in the medication cart and unlocked, and said normally the medication cart was locked when unattended and the keys in CMA N's pocket. CMA N stated they left the cart unlocked because a resident was leaving for dialysis and needed medication before leaving the facility. Interview on 08/30/22 at 09:00AM with Licensed Nurse (LN) H revealed when not using the medication cart,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2026-03-04 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
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 66 residents. Based on observations, interviews and record review, the facility failed to maintain and/or dispose of kitchen garbage and refuse properly.Findings included:- On 03/03/2026 at 07:30 AM, observation revealed two garbage receptacles outside, one on the east side and one on the west side. The garbage receptacle outside of the [NAME] House had the lid open on one side, and there were several bags of garbage behind the dumpster that had holes in them as if broken open, gloves, food, and other medical supplies noted. There was garbage on the ground on the side of the dumpster. Dietary CC reported that the lids should always be closed, and the garbage behind and on the side of the container should not be there. On 03/03/2026 at 10:35 AM, Dietary BB reported that there should be no garbage on the ground at the trash dumpsters and the lids should be closed. On 03/03/2026 at 12:30 PM, Administrative Staff A reported that she had been working on a little project regarding 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| AXIOM HEALTHCARE ALLIANCE, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 09/01/2020 |
| AXIOM CONSULTING LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 9% | since 09/01/2020 |
| DENNIS L. ROSS POD TO TRUSTEE OF DENNIS L. ROSS LIVING TRUST U/A 4/4/1 | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 5% | since 09/01/2020 |
| MATT LILLIE INVESTMENTS, INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 8% | since 09/01/2020 |
| ROGER EVANS REVOCABLE TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 6% | since 09/01/2020 |
| WICHITA WELLNESS INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 11% | since 09/01/2020 |
| EVANS, ROGER | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 6% | since 09/01/2020 |
| HERMES, FREDERICK | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 9% | since 09/01/2020 |
| LAKIN, GREGORY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 11% | since 09/01/2020 |
| LILLIE, MATTHEW | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 8% | since 09/01/2020 |
| ROSS, ANN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 5% | since 09/01/2020 |
| ROSS, DENNIS | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 5% | since 09/01/2020 |
| KRUSE, BRENDA | Individual | W-2 MANAGING EMPLOYEE | — | since 08/29/2018 |
| BECNEL, CHANCE | Individual | CORPORATE DIRECTOR | — | since 08/29/2018 |
| AXIOM HEALTHCARE SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/01/2007 |
7 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 14% 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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in KS
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Kansas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175501. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-04, 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.