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Via Christi Village Ridge

3636 North Ridge Rd Bldg 400, Wichita, KS 67205 · Non profit - Corporation · 80 certified beds · (316) 462-7502 Medicare & Medicaid certified

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Flagged for abuse2 actual-harm citations$36,040 in federal fines1 Medicare payment denial
Insights

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

In its favor
  • a high payroll-based staffing rating (5/5)
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2026
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $36,040 in federal fines (most recent 2026-02-11)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • 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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
Pharmacy
3510 N Ridge Rd Ste 900 · (316) 773-0412 · Call to confirm hours
Grocery
10222 W 21st St N · (316) 729-1530 · Call to confirm hours
Park
3805 N Lake Ridge Ct · Typically dawn to dusk

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 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.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased17.5%17.9%15.4%worse
Long-stay residents who lose too much weight4.0%4.9%5.4%better
Long-stay residents with a catheter left in their bladder0.0%1.6%0.9%better
Long-stay residents with a urinary tract infection0.7%2.9%2.0%better
Long-stay residents with depressive symptoms2.9%6.5%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury7.8%4.3%3.3%worse
Long-stay residents whose ability to walk worsened32.5%16.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication12.3%23.2%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.5%95.3%typical
Long-stay residents with pressure ulcers2.7%4.4%4.7%better
Long-stay residents with worsening bladder/bowel control27.9%22.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table9.6%18.1%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.9%1.4%better
Short-stay residents given the seasonal flu vaccine96.1%73.8%79.4%better
Short-stay residents rehospitalized after admission23.2%22.4%22.6%typical
Short-stay residents with an outpatient ER visit12.2%11.5%12.0%typical
Long-stay hospitalizations per 1,000 resident days0.311.801.67better
Long-stay outpatient ER visits per 1,000 resident days0.662.131.80better

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.

62.7% 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 409 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

62.7%U.S. median 51.5%
Got home and stayed home
11.5%U.S. median 10.7%
Went back to hospital
54.0%U.S. median 56.6%
Met the expected recovery
0.51U.S. median 0.31
Therapy hours / resident / day
0.27hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 54.0% 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 211 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 0.51 therapist hours per resident per day in 2026Q1 — more than 82% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF62.7%CMS range 58.3–66.351.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.5%CMS range 9.5–14.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge54.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge39.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge47.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified94.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting99.3%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge97.3%98.7%Oct 2024–Sep 2025CMS 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 stay0.8%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.3%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.4%CMS range 3.6–7.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.741.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

1.17
RN hours/ resident / day
0.94
LPN hours/ resident / day
2.37
Aide hours/ resident / day
4.47
Total nurse hours/ resident / day
0.81
RN hoursweekends
38.2%
Total nursing turnover
40.9%
RN turnover

How full it usually is: this home is certified for 80 beds and averages 72.5 residents a day — about 91% occupied, or roughly 8 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 4.47 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.17 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.37 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.96 hrs/resident/day on weekends vs 4.68 on weekdays — 15% thinner on weekends. RN hours go from 1.31 to 0.81 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 38% 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

8
deficiencies at the latest standard inspection (2026-02-11)
6
at the previous standard inspection (2024-04-04)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

22 citations, most serious first. The 12 most serious are shown; the remaining 10 are one tap away and print in full.

  • Actual harm · G2026-02-11 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 69 residents. The sample included 17 residents, with one resident reviewed for pain and activities of daily living (ADL). Based on observation, interview, and record review, the facility failed to ensure Resident (R) 55 remained free from neglect when the facility failed to provide necessary care and services staff were aware R55 needed and had multiple failures, which resulted in delayed healing, physical discomfort, and decreased quality of life. Findings included:- R55's Electronic Medical Record (EMR) revealed diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), contact dermatitis (skin rash), and overactive bladder. R55's 01/07/26 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 14, which indicated intact cognition. R55's MDS documented no behaviors and minimal depression. R55 required total assistance with toileting hygiene, transfers, and bed mobility. R55 was always…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-06-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 56 residents with three residents reviewed for falls. Based on record review and interview, the facility failed to immediately implement interventions to prevent further falls for Resident (R) 1 after R1 had to be lowered to the floor when her left leg buckled underneath her. This failure led to another staff-assisted fall later the same day. As a result of this deficient practice, R1 sustained a severe fracture of the left ankle. This deficient practice also placed R1 at risk for pain, impaired mobility, and decreased independence. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), dementia (progressive mental disorder characterized by failing memory, and confusion), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and hypertension (high blood pressure). R1's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-02-11 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 69 residents. The sample included 17 residents. Based on interviews, observation and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) and failed to follow appropriate infection control practices related to hand hygiene, sanitization of shared equipment, and sanitary storage of respiratory equipment. Findings included:1. On 02/09/26 at 11:05 AM, Certified Nurse Aide (CNA) N and CNA O assisted R55 to bed using the mechanical lift. R55 had a colostomy (a surgical creation of an artificial opening on the stomach wall to excrete feces from the body). CNA N and CNA O did not apply a gown during this care. CNA N used her gloved hands to open R55's drawer to retrieve the hygiene wipes. She wiped the red areas of R55's inner thighs several times using that same wipe. Staff assisted R55 to her side, and CNA N washed the resident's buttocks. Wearing the same gloves, she sprayed…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-11 · tag F0628 — isolated
    Provide 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 The facility had a census of 69 residents. The sample included 17 residents with five reviewed for discharge and two for hospitalization. Based on interviews and record review, the facility failed to provide a written bed hold policy at the time of transfer for Resident (R)75 and R3. Findings included: 1. R75's Electronic Medical Record (EMR) recorded an admission Minimum Data Set (MDS) dated [DATE], which documented, per staff interview, that the resident had short-term and long-term memory problems. The resident admitted on [DATE]. R75's Nursing Progress Notes, dated 01/05/26 at 05:37 PM, documented the nurse called emergency services based on a physician order to send the resident to the hospital. The resident was transferred to the hospital on [DATE] at 05:15 PM. The Transfer Form, dated 01/05/26 at 04:03 PM, documented the facility would provide the resident and/or representative with a bed hold that included the daily room rate and duration of the bed hold prior to transfer. However, the documentation…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-11 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    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 69 residents. The sample included 17 residents. Based on interview, observation, and record review, the facility failed to provide services to meet professional standards of care when staff failed to ensure Resident (R) 7's Electronic Medical Record (EMR) contained appropriate documentation for the schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) diagnosis. Findings included:- R7 's EMR revealed diagnoses of schizophrenia, and dementia (a progressive mental disorder characterized by failing memory and confusion). R7's Annual [NAME] Data Set (MDS), dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. R7's MDS revealed a diagnosis of schizophrenia. R7's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 09/30/25, documented R7 was at the facility for long term care. R7 had dementia and required staff 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 69 residents. The sample included 17 residents with two residents reviewed for activities of daily living (ADL). Based on observation, record review, and interview, the facility failed to ensure staff provided ADL assistance with personal hygiene for Resident (R) 55 and R63, who did not receive fingernail care and facial hair removal, and R8 who did not receive staff assistance to get dressed. Findings included:1. R55's Electronic Medical Record (EMR) revealed diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), contact dermatitis (skin rash), and overactive bladder. R55's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 14, which indicated intact cognition. R55's MDS documented that she had no rejection of care during the observation period and minimal depression. R55's MDS documented that she required total assistance with personal hygiene. R55's Care Plan,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-11 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 69 residents. The sample included 17 residents with one reviewed for hearing aid use. Based on interview and record review, the facility failed to ensure Resident (R) 8 received the necessary services, including staff assistance, with his hearing devices. Findings included: - R8's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), acoustic neuroma (typically slow-growing tumor that develops on the main nerve connecting the inner ear to the brain) with hearing loss, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R8's Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R8 required moderate assistance with personal hygiene. The MDS noted R8 had minimal difficulty with hearing and R8 used…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-11 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure 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. The sample included 17 residents. Based on observation, interview and record review the facility failed to ensure Resident (R) 31 remained free from significant medications errors when staff held metoprolol without a physician's order and did not contact the physician regarding the held medication. Findings included: - R31's Electronic Medical record (EMR) revealed the following diagnosis: hypertension (elevated blood pressure). R31's admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The medication section did not indicate hypertension. R31's Quarterly MDS, dated 02/02/26, indicated no changes to R31's BIMS or medications. R31's Care Plan, dated 11/06/25, noted R31 had hypertension and documented it would remain stable. Staff were to monitor R31's blood pressure and monitor and report side effects of medication. The plan directed staff to inform the physician of any…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-23 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 72 residents. Three residents were reviewed for privacy and confidentiality in their care at the facility. Based on observation, interview and record review, the facility failed to protect the privacy of Resident (R) 1 when Certified Nurse Aide (CNA) M took a video of R1 without R1's consent.Findings included:- The Electronic Medical Record (EMR) documented R1 had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). R1's Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status BIMS score of 99, indicating severely impaired cognition. The MDS noted R1 required the assistance of one staff member with activities of daily living (ADLs).R1's Quarterly MDS dated [DATE] indicated a BIMS score of 99, indicating severely impaired cognition. R1 required assistance from one staff member with all ADL. R1's Care Plan, revised 05/27/25, indicated R1 required extensive assistance from one staff member for bed 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-04 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure 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 reported a census of 72 residents. The facility identified four medication storage rooms and six medication carts used to administer medication to the residents. Based on observations, interviews, and record review, the facility failed to ensure that the medication administration error rate was no greater than five percent (%) when errors occurred with 22 of 27 observed medications had errors when the Licensed Nurse (LN) failed to confirm the medications administered against the physician's order or the eMAR (electronic medication administration record). The medication errors were due to failure follow nursing standard of care which resulted in an error rate of 81.48%. Findings include: - On 04/04/24 at 07:30 AM, LN D administered two medications to Resident (R) 8 by removing them from an outer wrapper (which was labeled with the identification of the contents) and removed the medications from their internal wrapping (which were also individually labeled with the identification of the contents) and failed to confirm the medications against the physician's order or 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-04 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility census totaled 72 residents residing on four neighborhoods. Based on observation, interview, and record review. the facility failed to secure medications by the failure to lock two medication carts on two separate neighborhoods during administration of medications when nursing staff left the medication cart unlocked and unattended. This had the potential to affect 20 residents residing on neighborhood D2 and 20 residents on B2. Findings included: - On 04/03/24 at 11:35 AM, the medication cart on D2 neighborhood was unlocked with no nurse in the vicinity of the cart. On 04/03/24 at 11:35 AM, Licensed Nurse (LN) D reported there were 20 residents on the neighborhood who received medications from the medication cart. LN D stated the cart contained narcotics and insulins as well as other medications. LN D reported that all medication carts should be locked when unattended and confirmed that the medication cart was unlocked and unattended. On 04/04/24 at 09:12 AM, on B2 neighborhood, a medication cart was noted unlocked and unattended while LN C administered medications to a…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-04 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 72 residents with 18 residents sampled. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program with the failure of staff to follow infection control standards when delivering meal trays to residents in the dining area, appropriately clean respiratory equipment for Resident (R) 8, R45 and R223 or perform hand hygiene between phases of wound care for R28. This deficient practice has the potential to lead foodborne illness, respiratory illness and wound infections. Findings include: - On 04/03/24 at 12:15 PM, Certified Nurse Aide (CNA) G and CNA H observed carrying multiple plates from satellite kitchen area in the D-200 neighborhood to resident tables with their thumbs over the edge of the plate and deep into the eating surface of the plates. On 04/03/24 at 12:25 PM, CNA G and CNA H revealed staff should carry resident plates by the bottom of the plate, without their fingers on the eating surface of the plates. On 04/03/24 at 12:36 PM, Dietary Staff I revealed that all staff,…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · E2024-04-04 · tag F0887 — pattern
    Educate 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

    The facility reported a census of 72 residents with 18 residents included in the sample. Based on interview and record review, the facility failed to ensure the five residents/ resident representatives acknowledged receipt related to COVID-19 (highly contagious respiratory virus) vaccination information/education for five of five residents, that included Resident (R)126, R124, R45, R6, and R16. Findings included: - On 04/04/24 at 12:20 PM, Administrative Nurse B provided an electronic spread sheet related to resident immunizations. The following were areas of concern: Resident (R)126 documentation revealed the COVID vaccination as Resident refused, however the facility was unable to provide declination information. R124 documentation revealed as resident refused, however the facility was unable to provide declination information. R45's documentation revealed the resident received a COVID vaccination on 10/13/23, however, lacked education for the risk verses benefits. Furthermore, the facility failed to provide a written consent to administer the vaccination. R6's documentation…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 72 residents with 18 residents sampled, that included three residents reviewed for accident hazards. Based on observations, interviews, and record review, the facility failed to provide an environment as free of accident hazards as possible for Resident (R)28, when the facility failed to prevent multiple electrical cords plugged into two power strips next to R28's recliner from being strewn about the floor in the walking path between R28's recliner and R28's bed and the oxygen tubing on the floor in the walking path from the bathroom to R28's bed and recliner area. This deficient practice had the potential to create a trip hazard for R28 that could potentially lead to injury. Findings included: - R8's diagnoses from the Electronic Health Record (EHR) documented chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), other disorders of the lung, and Parkinson's (a slowly progressive neurologic disorder characterized by resting tremor,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-04 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY - R8's diagnoses from the Electronic Health Record (EHR) documented chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), other disorders of the lung and obstructive sleep apnea (OSA - a sleep disorder that causes repeated breathing interruptions during sleep). The 09/29/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required extensive assistance for all cares except eating and ambulation which were independent. The MDS documented no falls since admission and R8 received oxygen and a non-invasive mechanical ventilator via CPAP (continuous positive airway pressure - a ventilation device that blows a gentle stream of air into the nose to keep airway open during sleep). The 09/29/23 ADL (activities of daily living, such as combing/brushing hair, brushing teeth, dressing and toileting) Functional /…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-11 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 61 residents with 15 sampled. Based on observation, interview, and record review the facility failed to promote dignity when staff failed to empty a suction canister for Resident (R) 10, which contained yellow liquid and was visible to all visitors who entered the room, through three days of observations. Findings included: - Review of R10's pertinent diagnoses from the Electronic Health Record (EHR) documented: dementia (progressive mental disorder characterized by failing memory, confusion) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The 10/25/21 Significant Change Minimum Data Set (MDS) documented a staff assessment indicated long and short-term memory problem with severely impaired cognition. R10 received hospice services. The 01/28/22 Quarterly MDS documented R10 received hospice services and suctioning. The 01/22/22 Care Plan documented R10 received hospice services and as of 10/29/21 the resident had suctioning available, as needed (PRN). The EHR documented an order on 10/16/21…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-11 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 61 with 15 residents in the sample. Based on observation, interview, and record review the facility failed to revise a care plan for one Resident (R) 30 regarding the use of a nebulizer (a respiratory treatment). Findings included: - The Physician Order dated 03/02/22 indicated the following diagnoses: viral pneumonia (an infection in the lungs) and chronic respiratory failure (chronically poor airflow). The admission Minimum Data Set dated 03/07/22 indicated R30 received oxygen therapy. The 03/07/22 Care Plan indicated R30 had a potential for shortness of breath and/or respiratory complications related to pneumonia and chronic bronchitis. Staff were to provide treatment per physicians' orders and monitor the resident for response. The 03/07/22 Care Plan lacked interventions related to the use of the nebulizer and/or the care of the nebulizer after each treatment The 03/07/22 Physician Order included the medication Albuterol Inhalation Solution 0.083% to be delivered by nebulizer at 2.5 mg (milligrams) in 3 milliliters (mL) inhalation, every 12…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-11 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 61 residents with 15 sampled. The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for three residents. The facility failed to notify the provider of weight fluctuations greater than two pounds (lbs.) as ordered and failed to document the application of ace wraps and tubigrip bandages (an elasticated tubular bandage used for support) for Resident (R) 16. The facility also failed to document treatments as ordered by the provider for R15 and failed to change the wound dressing daily, as ordered for R25. Findings included: - Review of R16's pertinent diagnoses from the Electronic Health Record (EHR) documented: heart failure (a condition with low heart output and the body becomes congested with fluid) and lymphedema (swelling caused by accumulation of lymph). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-04-11 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    - R20's Electronic Health Record (EHR) documented the following diagnoses under the medical diagnoses tab: chronic obstructive pulmonary disease (COPD, progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The 11/20/21 Annual Minimum Data Set (MDS) documented R20 had a Brief Interview for Mental status (BIMS) score of four, indicating severely impaired cognition, with use of oxygen noted. The 02/15/22 Care Plan documented staff were to provide R20 treatments as ordered and monitor for response. The EHR documented an order for R20 on 07/14/21 for albuterol sulfate (bronchodilator- works by relaxing and opening air passages to the lungs) nebulization (electrically powered machine that turns liquid medication into a mist) solution 2.5 milligrams (mg)/milliliter (ml) two times daily and as needed (PRN). On 04/05/22 at 01:52 PM, observation revealed R20's O2 mask for nebulized medication sat on her bed with no…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-11 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 61 residents, with 15 in the sample, and five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to report three blood sugars over the parameters of 290 milligrams per deciliter (mg/dL) as ordered by the physician for Resident (R) 4. Findings included: - R 40's signed Physician Orders dated 03/15/22 revealed the diagnosis of diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Medications received included insulin injections daily in the seven-day observation period. The Care Plan dated 03/14/22 revealed R40 had a potential for complications from diabetes. Approaches included the staff were to administer medications per physician orders, monitor for side effects and notify physician as needed (PRN),…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-04-11 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 61 residents. Based on observation, interview, and record review the facility failed to ensure nursing staff stored a suction catheter sanitarily to prevent infection for Resident (R) 10. The facility further failed to clean a glucometer (instrument used to calculate blood glucose) after use to reduce the risk of spread of infectious diseases. Findings Included: - On 04/04/22 at 03:32 PM observed R10's room with a suction canister on suction machine, with yellow liquid in the canister and sitting on the bedside table with the tubing and a Yankauer (an oral suctioning tool used in medical procedures) suction catheter tip set directly on the bedside table, with no barrier noted. On 04/05/22 at 01:09 PM observed R10's room with a suction canister on suction machine, with yellow liquid in it, sitting on the bedside table and the tubing with a Yankauer suction catheter tip set directly on the bedside table, with no barrier noted. On 04/06/22 at 09:33 AM observed R10's room with a suction canister on suction machine, with yellow liquid in it, sitting 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2026-02-11 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 69 residents. Based on observation and interview, the facility failed to provide housekeeping and maintenance services to ensure a safe and sanitary environment for residents and staff in the facility laundry. Findings included:- On 02/11/2026 at 12:30 PM, the tour of the facility laundry with Laundry/Housekeeping Staff U and Maintenance Staff V revealed the following concern. Three linen bins had soiled laundry, but were not covered. A 10-foot by four-inch area on the wall had peeling, unsealed, and unsanitary sheetrock. Two clean linen storage bins used for the delivery of clothes throughout the facility had frayed, unsanitary fabric around the top of the bins in an area that would have direct contact with clothes. On 02/11/26 at 12:53 PM, Laundry Staff U and Maintenance Staff V confirmed the above findings. They reported they were unaware that the soiled linen should be covered and were unaware of the inability to sanitize the clean clothes bins due to the frayed fabric. The staff verified that the sheetrock along the wall was unsealed and needed…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$36,040 in federal fines across 1 penalty. 1 Medicare payment denial on record.

  • $36,040 — penalty dated 2026-02-11
  • Medicare payment denial — starting 2026-03-12 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 ASCENSION LIVING — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 52.8+1.2 vs chain
Health inspection 2 of 52.4-0.4 vs chain
Staffing 5 of 53.9+1.1 vs chain
Quality measures 5 of 53.4+1.6 vs chain
The other 11 homes this chain runs (chain average 2.8★, 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 / managerTypeRoleShareSince
ASCENSION HEALTH SENIOR CAREOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 07/01/2014
MUSGRAVE, LISAIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 01/01/2024
SMOOT, KENNETHIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 01/01/2024
SHADBOLT, ERINIndividualCORPORATE OFFICER; ADP OF THE SNFsince 01/01/2024
LOYD, MICHAILIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/30/2024
MCCUE, TAMARAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/02/2023
HEALTH DIMENSIONS CONSULTING INCOrganizationADP OF THE SNFsince 08/02/2019
INTERIM HEALTH CARE OF WICHITA INCOrganizationADP OF THE SNFsince 03/08/2023
MEDICAL SOLUTIONS LLCOrganizationADP OF THE SNFsince 06/17/2017
WEISS STAFFING SOLUTIONSOrganizationADP OF THE SNFsince 10/20/2022

CMS files one row per role, so the 16 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.

$13.8M
Net patient revenuemost recent cost report
+0.7%
Operating marginrevenue minus expenses
$2.0M
Related-party expense15% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 10%Other / private 90%

This home reported $2.0M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$281per resident / day
operating cost
$8,547per month
≈ monthly operating cost
$283per day
avg. revenue, all payers

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

What families pay in KS

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175539. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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