Rolling Hills Health And Rehab
1319 Seville Street, Wichita, KS 67209 · For profit - Corporation · 85 certified beds · (316) 722-6916 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $39,118 in federal fines (most recent 2024-01-23)
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 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.
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 | 21.1% | 17.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 0.9% | 4.9% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.9% | 2.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 2.2% | 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 | 4.1% | 4.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 17.4% | 16.2% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 23.2% | 23.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.8% | 4.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 22.3% | 22.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.9% | 18.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.0% | 1.9% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 91.7% | 73.8% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.7% | 22.4% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 7.6% | 11.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.70 | 1.80 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.81 | 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.
45.7% 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 39 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 37.5% 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 40 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 0.22 therapist hours per resident per day in 2025Q4 — more than 27% of the 13,714 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 14% — 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 | 45.7%CMS range 33.7–61.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.3%CMS range 6.5–15.9 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 37.5% | 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 | 42.5% | 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 | 40.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.3% | 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 | 95.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 3.3% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.0%CMS range 3.8–13.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.26 | 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 85 beds and averages 65.8 residents a day — about 77% occupied, or roughly 19 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.82 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.45 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.56 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.22 hrs/resident/day on weekends vs 3.95 on weekdays — 18% thinner on weekends. RN hours go from 0.52 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% 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
Deficiencies are unchanged from the previous inspection. 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.
26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.
- Immediate jeopardy · J2024-01-23 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 69 residents with 13 selected for review. Based on observation, interview, and record review, the facility failed to maintain comfortable and safe temperature levels of 71 degrees Fahrenheit (F) or greater for ten residents, Resident (R)2, R5, R6, R7, R8, R9, R10, R11, R12, R13 when a facility furnace quit working mid-morning on 01/12/24. The furnace supplied heat to one of four wings, covering six resident rooms, with ten residents affected. Following the breakdown, a repairman came to the facility that afternoon and determined the part needed to repair the furnace required ordering. The facility placed portable infrared space heaters in the resident rooms until 01/16/24 at 02:04 PM, at which time the Fire Marshall instructed the facility to remove the space heaters. One of the ten residents, R8, moved to another room on another wing, while the nine other residents affected chose to remain in their rooms. The facility failed to monitor and document temperatures of the resident rooms until 01/17/24, after the surveyor was on site, and failed to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · Jcited before2024-01-23 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 thirteen sampled, and three reviewed for significant medication errors. Based on observation, record review, and interview, the facility failed to prevent a significant medication error for Resident (R)1 when facility staff prepared and wrongly administered R4's medications, which included high risk medications, to R1 on 12/18/23. Certified Medication Aide (CMA) R prepared R4's medications, then asked R1 if she was ready for her medication and R1 nodded yes, so CMA R administered R4's medications to R1. CMA R thought R1 resembled the picture in the Medication Administration Record (MAR) for R4. Shortly after administration of the medications, CMA R heard Administrative Nurse E speak to R1 and realized she administered R4's medications to R1. R1 had a change in condition, her blood pressure dropped, and she required emergency medical service intervention. Staff transferred R1 to the hospital via emergency medical services and R1 admitted to observation 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 · F2026-06-24 · 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
Based on observation and interviews, the facility failed to follow sanitary dietary standards related to food storage, unclean floors, and monitoring of dishwasher temps. Findings included:- During the initial tour on 06/22/2026 at 07:42 AM, observation revealed the following:The floors were sticky and dirty, thick dark dirt was around all standing work area legs. There was a cup of pudding with whipped topping in the single refrigerator that was undated and unlabeled. There were seven small bags of chicken in a steam table pan that were unlabeled and undated in the two-door refrigerator.The dishwasher was missing temperature recordings for 06/19/2026, 06/20/2026, 06/21/2026, and 06/22/2026.On 06/22/2026 at 08:00 AM, Dietary Staff BB stated the floors needed deep cleaning. He stated the kitchen floors were deep cleaned twice a year. Dietary Staff BB stated staff mopped the floor every night. He said the chicken was brought in by a family member, and the bags should have been dated before they were placed in the refrigerator. Dietary Staff BB stated he would dispose of the pudding…
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 · E2026-06-24 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to offer and provide or obtain informed declination for the influenza and pneumococcal vaccination for Resident (R) 1, R5, R49, and R62 or their representative. Findings included:- The Electronic Medical Record (EMR) for R1, R5, R49, and R62, lacked evidence of an informed declination for the influenza and pneumococcal vaccinations. The Immunizations tab for the above residents noted that the vaccinations had been offered but refused by the residents.Upon request, the facility was unable to provide documentation that the vaccination information, including risks verses benefits was provided to R1, R5, R49, and R62 and was unable to provide documentation of informed declination.On 06/24/2026 at 10:25, Licensed Nurse (LN) G, the facility Infection Preventionist, stated that each fall the influenza and pneumococcal vaccination was offered to residents. If the resident chose to get the vaccination, it was given. LN G stated the facility did not have residents or their representative sign a consent to decline 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 · E2026-06-24 · tag F0887 — patternEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to obtain an informed declination for the COVID-19 vaccination was provided for Resident (R)1, R5, R49, and R62 or their representative. Findings included:- Review of Electronic Medical Record (EMR) for R1 lacked evidence of informed declination for the COVID-19 vaccination. The Immunizations tab for R1 noted that the vaccinations had been offered June 2026 but refused by the resident.R5's EMR lacked evidence of informed declination for the COVID-19 vaccination. The Immunizations tab for R5 noted that the vaccinations had been offered June 2026 but refused by the resident.R49's EMR lacked evidence of informed declination for the COVID-19 vaccination. The Immunizations tab for R49 noted that the vaccinations had been offered June 2026 but refused by the resident.R62's EMR lacked evidence of informed declination for the COVID-19 vaccination. The Immunizations tab for R62 noted that the vaccinations had been offered June 2026 but refused by the resident.On 06/24/2026 at 10:25 AM, Licensed Nurse (LN) G, the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-24 · tag F0582 — isolatedGive 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
Based on interviews and record review, the facility failed to provide the correct Center for Medicare and Medicaid (CMS) Form 10055, Advanced Beneficiary Notice (ABN), for two residents, Resident (R)34 and R55. Findings included:- The Medicare ABN form informed the beneficiaries Medicare may not pay for future skilled therapy and did not provide an estimated cost to continue their services. The form included options for the beneficiary to () receive specified services listed, and bill Medicare for an official decision on payment. I understand if Medicare does not pay, I will be responsible for payment, but I can appeal to Medicare. (2) receive therapy listed, but do not bill Medicare, I am responsible for payment of services. (3) I do not want the listed services.The facility's Medicare ABN form staff provided to R34 (or their representative) was form CMS-R-131 for the last covered day of 02/10/2026.The facility's Medicare ABN form staff provided to R55 (or their representative) was form CMS-R-131 for the last covered day of 06/02/2026.On 06/23/2026 at 01:30 PM, Social Service X…
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 · D2026-06-24 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interviews, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for Resident (R) 62. Findings included:- R62's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses ofanxiety, major depressive disorder, dementia (a progressive mental disorder characterized by failing memory and confusion), and need for assistance with personal care. R62's admission Minimum Data Set (MDS) dated 05/07/2026 documented a Brief Interview of Mental Status (BIMS) score of six, which indicated severely impaired cognition. The MDS documented R62 received antipsychotic medication and an antidepressant medication during the observation period. R62's Psychotropic Drug Use Care Area Assessment (CAA) dated 05/07/2026 documented R62 triggered due to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-24 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide Resident (R) 5, or their representative with a copy of the bed hold policy, written notification of transfer, and failed to notify the ombudsman when she was transferred to the hospital. The facility failed to ensure the Notice of Transfer to Hospital form included the required rights to appeal and the ombudsman information. Findings included:1. R5's Electronic Medical Record (EMR) recorded a Discharge Minimum Data Set (MDS) for an unplanned discharge to an acute hospital with a return anticipated on 04/30/2026.R5's Entry MDS dated 05/06/2026 recorded a reentry to the facility from an acute setting.R5's EMR lacked documentation the facility provided the bed hold, notice of transfer, and notification to the ombudsman for R5's transfer to the hospital on [DATE]. Upon request, the facility was unable to provide.R5's Entry MDS dated 05/06/26 recorded a reentry to the facility from an acute setting.2.R9's EMR recorded a Discharge 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 · Dcited before2026-06-24 · 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 Based on observation, interview, and record review, the facility failed to implement effective person-centered interventions to prevent falls for two residents. Resident (R)38, who had three falls with staff, and R1, whose fall interventions were not implemented. Findings included:- R38's Electronic Health Record (EHR) revealed diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body), reduced mobility, muscle weakness, and absence of the right upper limb.The Annual Minimum Data Set (MDS), dated [DATE], documented R38 had intact cognition. R38 required substantial staff assistance for oral hygiene, personal hygiene, mobility, transfers, and upper body dressing. R38 had upper body functional impairment on one side, lower body functional impairment, had no falls, and did not ambulate.The Quarterly MDS, dated 05/29/2026, documented R38 had intact cognition. R38 was dependent on staff for transfers, toileting, hygiene, and substantial assistance with mobility, upper-body dressing, 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 · D2026-06-24 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to collaborate care and services provided by the facility with the care and services provided by hospice for Resident (R)11. Findings included:- R11's Electronic Health Record (EMR) documented diagnoses of senile degeneration of the brain (the progressive deterioration of brain cells and their connections, leading to cognitive decline and behavioral changes in older adults), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), pain, and adult failure to thrive (includes not doing well, feeling poorly, wight loss, and poor self-care that could be seen in elderly individuals). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R11 had severely impaired cognition. R11 was dependent upon staff for all activities of daily living (ADLs). The MDS documented R11 received hospice services.R11's 06/22/2026 Care Plan included the following interventions for R11:09/15/2025- administer medications for comfort before an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-24 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to implement adequate infection control practices related to sanitary storage of respiratory supplies and hand hygiene during wound care for Resident (R) 4. Findings included:- On 06/22/2026 at 07:55 AM, during the facility walk through, R20's nasal cannula laid on his bed, R20's nasal cannula (a lightweight, flexible device that delivers supplemental oxygen directly into your nose) was not stored in a sanitary container. R20's nebulizer mask (a device that changes liquid medication into a mist easily inhaled into the lungs) laid uncovered on her bedside table, R20's nebulizer was not stored in a sanitary container. R68's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask laid on the bottom of her bed, R68's feet laid on the CPAP mask. R68's CPAP mask was not stored in a sanitary container. On 06/23/2026 at 08:55 AM, Consultant GG and her assistant entered R4's room and put on a gown. Licensed Nurse (LN) G was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-11-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 64 residents. The sample included 17 residents, with four reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure a safe environment free from accident hazards for Resident (R) 6 when staff did not use the right type of slide board for R6, who had a previous staff-assisted fall using a slide board. The facility further failed to address the risk after a staff-assisted fall. The facility failed to ensure a safe environment free from accident hazards for R10, who had large openings in the side rails presenting a risk for entrapment. Additionally, the facility failed to ensure a safe environment for R47 who had medications stored on her bookshelf, and for R52 who did not wear a smoke apron as per her plan of care while smoking. These failures placed the affected residents at risk for preventable accidents and related injuries. Findings included: - The Electronic Medical Record (EMR) for R6 documented diagnoses of cerebrovascular accident…
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 · D2024-11-20 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 64 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to revise the care plan for one resident, Resident (R)40, whose hydrochlorothiazide (HCTZ-a diuretic) was discontinued. This placed the resident at risk for inappropriate care due to uncommunicated care needs. Findings included: - The Electronic Medical Record (EMR) for R40 documented diagnoses of bradycardia (low heart rate, less than 60 beats per minute), cerebrovascular accident (CVA-stroke-sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), chronic kidney disease ( longstanding disease of the kidneys leading to renal failure), hypertension (high blood pressure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypotension (low blood pressure), acute kidney failure (a condition in which the kidneys suddenly can't filter waste…
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 · D2024-11-20 · 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
The facility had a census of 64 residents. The sample included 17 residents with one reviewed for dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). Based on observation, record review, and interview, the facility failed to ensure ongoing communication with the dialysis provider regarding dialysis treatments and monitoring for Resident (R)54. This placed the resident at risk for complications and health decline. Findings included: - R54's Electronic Health Record (EHR) documented R54 had a diagnosis of stage four chronic kidney disease (CKD- a critical phase when kidneys are severely damaged and can't filter waste from the blood properly). R54 Annual Minimum Data Set (MDS), dated 9/21/24, recorded R54 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS recorded R54 required setup assistance with eating, upper and lower body dressing, putting on and taking off footwear, personal hygiene, sitting to lying, supervision with oral hygiene, toileting…
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 · D2024-11-20 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 64 residents. The sample included 17 residents, with one reviewed for side rails. Based on observation, record review, and interview, the facility failed to obtain written informed consent which included potential risks versus benefits from the resident and/or representative for the use of side rails for Resident (R)10. This placed her at risk for accident or injury due to uninformed choices regarding side rail use. Findings included: - The Electronic Medical Record (EMR) for R10 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R10 had severely…
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 · D2024-11-20 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 64 residents. The sample included 17 residents, with four reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure Certified Nurse Aide (CNA) staff possessed adequate competency and skill for the use of a slide board for one resident, Resident (R) 6, who was lowered to the ground during a slide board transfer. This placed the resident at risk for injury. Findings included: - The Electronic Medical Record (EMR) for R6 documented diagnoses of cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) affecting the left non-dominant side, muscle weakness, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (high blood pressure), and obesity (excessive 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.
- Potential for harm · D2024-11-20 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure 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 had a census of 64 residents. The sample included 17 residents, with five reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist identified and reported the lack of an appropriate indication, or the required physician documentation, for Resident (R) 37's use of an antipsychotic (medications used to treat any major mental disorder characterized by gross impairment in reality)and irregularities with R38's blood pressure and pulse monitoring. This placed the resident at risk for unnecessary medications and related side effects. Findings included: - R37's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), and major depressive disorder (MDD-major mood disorder which causes persistent feelings of sadness). R37's Annual Minimum Data Set (MDS), dated [DATE] recorded R37 had a Brief Interview for Mental Status (BIMS) score of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-20 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 64 residents. The sample included 17 residents of which five were reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to notify the physician when Resident (R) 38's blood pressure and pulse were outside the physician-ordered parameters. This placed the residents at risk for ineffective medication regimens and unnecessary medication side effects. Findings included: - R38's Electronic Medical Record (EMR) documented that R38 had a diagnosis of atherosclerosis ( a buildup of fats, cholesterol, and other substances in and on the artery walls) of the coronary arteries (blood vessels of the heart). R38's Annual Minimum Data Set (MDS), dated [DATE], documented R38 had a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented R38 had atherosclerosis. R38's Care Plan, revised 9/20/24, instructed staff to administer medications as the physician ordered. The plan 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 · D2024-11-20 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 64 residents. The sample included 17 residents, with five reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of Resident (R)37's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing) medication. This placed R37 at risk for unintended effects related to psychotropic (alters mood or thought) medications. Findings include: - R37's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), and major depressive disorder (MDD-major mood disorder which causes persistent feelings of sadness). R37's Annual Minimum Data Set (MDS), dated [DATE] recorded R37 had a Brief Interview for Mental Status…
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 before2024-11-20 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 63 residents, with 19 residents included in the sample. Based on observation, record review, and interview, the facility failed to prevent significant medication errors for one resident, Resident (R) 105, who did not receive medications that were ordered to treat high blood pressure. This placed R105 at risk for adverse complications due to high blood pressure. Findings included: - The Electronic Medical Record (EMR) for R105 documented a diagnosis of coronary artery disease (CAD- abnormal condition that may affect the flow of oxygen to the heart), hypertension (HTN-elevated blood pressure), end-stage renal disease (ESRD-a terminal disease of the kidneys), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), dependence on dialysis (procedure where impurities or wastes were removed from the blood). The Annual Minimum Data Set (MDS) dated [DATE], documented R105 had a Brief Interview for Mental Status (BIMS) score of 14, which…
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 · D2024-11-20 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 64 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to correctly prepare a pureed diet for two residents that retained both nutritive value and palatability. This placed the affected residents at risk for impaired nutrition or decreased quality of life. Findings included: - On 11/18/24 at 08:15 AM, observation revealed staff preparing and serving the breakfast meal to residents in the dining room. On 11/19/24 at 10:45 AM, observation revealed Dietary Staff (DS) CC prepared two pureed diets. DS CC placed two servings of California medley blend vegetables (cauliflower, broccoli, and carrots) into the Robot-coup blender (food processor) and added one tablespoon (tbsp) plus 1/8 teaspoon (tsp) of food thickener, one tbsp plus ¾ tsp of left-over vegetable juice and blended the food to the correct consistency. DS CC then placed the food in a metal pan and placed the pan in the hot water well on the hot holding cart. Observation revealed DS CC then placed three three-ounce servings of meatloaf,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-19 · 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 63 residents with 16 residents sampled, including one resident reviewed for admission, transfer, and discharge. Based on observation, interview and record review, the facility failed to notify in writing one Resident (R)116 and their representative of the intention to involuntarily discharge the resident from the facility, 30 days before the date of discharge. Findings included: - Review of Resident (R)116's electronic medical record (EMR) revealed a diagnosis of multiple sclerosis (MS - progressive disease of the nerve fibers of the brain and spinal cord). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. There was no active discharge planning for the resident to return to the community. The Activities of Daily Living (ADL) Function/Rehabilitation Potential Care Area Assessment (CAA), dated 03/22/22, documented the resident required extensive to total assistance of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-19 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 63 residents with 16 residents sampled, including six residents reviewed for Activities of Daily Living (ADL). Based on observation, interview, and record review the facility failed to complete appropriate personal hygiene for one dependent Resident (R)11, regarding long, jagged, dirty fingernails and failed to complete appropriate oral care for dependent resident R117. Findings included: - Review of Resident (R)11's electronic medical record (EMR), revealed diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body). The annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe impairment. He required extensive assistance of two staff for personal hygiene. Bathing did not occur during the assessment period. Review of the Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 02/06/22, did not trigger for further review. 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 · D2023-01-19 · 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 reported a census of 63 residents, with two residents reviewed for the care of a gastrostomy tube (G-tube) (a tube that is placed directly into the stomach through an abdominal wall incision for the administration of food, fluids, and medications, also called a PEG tube, percutaneous endoscopic tube.). Based on observations, interviews, and record review, the facility failed to provide appropriate and sufficient services, treatment, and care based upon current standards of practice to ensure that Resident (R) 13 received proper treatment and services to prevent infection of the stoma (surgically created opening of an internal organ on the surface of the body) where the G-tube inserted through the skin. Findings included: - Resident (R) 13's pertinent diagnoses from the 12/11/22 Physician Order Sheet included: dysphagia (swallowing difficulty) following other cerebrovascular diseases (group of conditions that affect the circulation of blood to the brain, causing limited or no blood flow to affected…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 63 residents with 16 residents sampled, including three residents reviewed for respiratory. Based on observation, interview and record review, the facility failed to provide appropriate respiratory care for one Resident (R)117, of the three sampled, regarding oxygen tubing to prevent respiratory infections. Findings included: - Review of Resident (R)117's electronic medical record (EMR), revealed diagnoses of hemiparesis (muscular weakness of one half of the body) and hemiplegia (paralysis of one side of the body). The admission Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed moderately impaired cognition. She used oxygen while a resident at the facility. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 12/07/22, documented the resident required extensive to total assistance with ADLs. The care plan, dated 12/18/22, lacked staff instruction for care of the resident's oxygen…
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 · C2026-06-24 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to submit complete and accurate staffing information through the Payroll Based Journal (PBJ) as required. Finding included:- The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2025, Quarter 3 and 4, and FY 2026, Quarter 1 and 2, indicated the facility had excessively low weekend staff.Review of the facility staffing schedule revealed adequate weekend staffing for the quarters above.On 06/24/2026 at 09:45 AM, Administrative Staff B stated she compared the timesheets and the payroll forms and submitted them to the corporate office. The payroll specialist at the corporate office looked it over, and then it was submitted to CMS. Administrative Staff B further stated that she did not understand why it showed low weekend staff, as there are the same number of staff on the weekend as there were during the week.On 06/24/2026 at 01:30 PM, Administrative Staff A stated that they discovered administrative staff had accidentally been reported as hands-on staff during the week, and then 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.
“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
$39,118 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $39,118 — penalty dated 2024-01-23
- Medicare payment denial — starting 2024-02-13 for 3 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to MISSION HEALTH COMMUNITIES — 29 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.9 | -0.9 vs chain |
| Health inspection | 2 of 5 | 2.9 | -0.9 vs chain |
| Staffing | 3 of 5 | 3.0 | ≈ chain avg |
| Quality measures | 3 of 5 | 2.9 | +0.1 vs chain |
The other 28 homes this chain runs (chain average 2.9★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| KANSAS OPERATOR LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 02/25/2015 |
| BARRES, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/26/2015 |
| T AND C CAPITAL ASSETS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/26/2015 |
| WINDWARD HEALTH PARTNERS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/26/2015 |
| CRINO, BRYAN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/26/2015 |
| FEUER, SCOTT | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/26/2015 |
| LINDEMAN, STUART | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | NO PERCENTAGE PROVIDED | since 02/26/2015 |
| PASSERO, JOSEPH | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/26/2015 |
| YOAKUM, JAMIE | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 03/22/2024 |
| MISSION HEALTH COMMUNITIES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 02/26/2015 |
CMS files one row per role, so the 12 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
5 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.
About 84% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $506K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in KS
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Kansas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-09-01 — CMS provider number 175253. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-24, 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.