Cycle 1
Health 2025-01-23 · Fire 2025-01-23
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Rose Hill, KS
Advena Living At Fountainview
3-star overall rating with 3-star inspections with $38,759 in total fines with 6 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
601 N Rose Hill Road, Rose Hill, KS
(316) 776-2194
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
42
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Advena Living Communities
Operator or chain grouping
Approved since
1992-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 2 overall / 2 health / 2 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.41
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.51
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.46
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.38
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
0.91
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.91
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.55
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
4.19
CMS adjusted total nurse staffing hours
Case-mix index
1.10
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
71%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,171
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.60
Composite VBP score used to determine payment impact.
Payment multiplier
0.9846
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
1.69
Performance 56.76% · Measure score 1.69 · Achievement 1.69 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.83
Baseline 4.14 hours · Performance 4.17 hours · Measure score 3.83 · Achievement 3.83 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.87% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 11.11% · Lower 95% interval 6.59% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 23 · Denominator 23 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 23 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 23 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 49 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 117 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.8
0.2 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.2 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.2
0.8 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.2 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.9% |
91.8%
4.1 pts better
|
93.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.6% · Q3 91.1% · Q4 97.4% · 4Q avg 95.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
95.5%
2.5 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.7% |
4.4%
0.3 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.2% · Q3 6.7% · Q4 7.7% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.8% |
5.6%
2.8 pts better
|
11.4%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 0.0% · Q3 3.4% · Q4 2.9% · 4Q avg 2.8% |
| Percentage of long-stay residents who lose too much weight | 0.7% |
5.0%
4.3 pts better
|
5.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.7% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.5% |
23.2%
9.3 pts worse
|
19.6%
12.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.5% · Q2 35.0% · Q3 32.4% · Q4 22.2% · 4Q avg 32.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 41.6% |
19.8%
21.8 pts worse
|
16.7%
24.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.5% · Q2 44.0% · Q3 39.1% · 4Q avg 41.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.3% |
18.4%
0.1 pts better
|
16.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 17.3% · 4Q avg 18.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.1% |
18.8%
4.3 pts worse
|
14.9%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.4% · Q2 10.3% · Q3 16.2% · Q4 35.3% · 4Q avg 23.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
1.8%
0.4 pts worse
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.5% · Q4 3.3% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
3.1%
2.5 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.3% |
23.2%
0.9 pts better
|
19.8%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.1% · Q2 22.5% · Q3 22.6% · Q4 21.8% · 4Q avg 22.3% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
4.6%
0.7 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 5.6% · Q3 3.0% · Q4 3.8% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.0% |
75.6%
4.4 pts better
|
81.7%
1.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q4 77.3% · 4Q avg 80.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.5% |
2.2%
2.3 pts worse
|
1.6%
2.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 4.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-23 · Fire 2023-01-23
21 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
30 fire-safety deficiencies
Top issue: Smoke (10 deficiencies)
Cycle 3
Health 2021-06-16 · Fire 2021-06-16
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
15 fire-safety deficiencies
Top issue: Miscellaneous (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-23
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-03-07
F · Potential for more than minimal harm
2025-01-23
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-03-07
F · Potential for more than minimal harm
2025-01-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-10
F · Potential for more than minimal harm
2025-01-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-07
F · Potential for more than minimal harm
2025-01-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-07
E · Potential for more than minimal harm
2025-01-23
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-03-11
E · Potential for more than minimal harm
2025-01-23
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2025-02-05
E · Potential for more than minimal harm
2025-01-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-07
E · Potential for more than minimal harm
2025-01-23
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-03-07
E · Potential for more than minimal harm
2025-01-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-03-07
E · Potential for more than minimal harm
2025-01-23
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-03-10
E · Potential for more than minimal harm
2025-01-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-07
F · Potential for more than minimal harm
2023-01-23
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2023-07-03
F · Potential for more than minimal harm
2023-01-23
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-06-26
F · Potential for more than minimal harm
2023-01-23
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-06-26
F · Potential for more than minimal harm
2023-01-23
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-07-03
F · Potential for more than minimal harm
2023-01-23
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-07-03
F · Potential for more than minimal harm
2023-01-23
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2023-06-26
F · Potential for more than minimal harm
2023-01-23
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-06-26
F · Potential for more than minimal harm
2023-01-23
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-06-26
F · Potential for more than minimal harm
2023-01-23
K252 · Egress Deficiencies
Fire Safety
Provide at least two remote exits on each floor or fire section of the building.
Corrected 2023-07-03
F · Potential for more than minimal harm
2023-01-23
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-06-26
F · Potential for more than minimal harm
2023-01-23
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-06-26
F · Potential for more than minimal harm
2023-01-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-26
F · Potential for more than minimal harm
2023-01-23
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-08-30
F · Potential for more than minimal harm
2023-01-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-03
F · Potential for more than minimal harm
2023-01-23
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-09-11
F · Potential for more than minimal harm
2023-01-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-26
F · Potential for more than minimal harm
2023-01-23
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-06-26
F · Potential for more than minimal harm
2023-01-23
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-06-26
F · Potential for more than minimal harm
2023-01-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-26
F · Potential for more than minimal harm
2023-01-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-06-26
F · Potential for more than minimal harm
2023-01-23
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-07-03
F · Potential for more than minimal harm
2023-01-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-26
F · Potential for more than minimal harm
2023-01-23
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-06-26
F · Potential for more than minimal harm
2023-01-23
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-07-03
F · Potential for more than minimal harm
2023-01-23
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-06-26
F · Potential for more than minimal harm
2023-01-23
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-07-03
E · Potential for more than minimal harm
2023-01-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-26
E · Potential for more than minimal harm
2023-01-23
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-03-28
E · Potential for more than minimal harm
2023-01-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-26
E · Potential for more than minimal harm
2023-01-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-06-26
F · Potential for more than minimal harm
2021-06-16
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2021-08-23
F · Potential for more than minimal harm
2021-06-16
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2021-08-23
F · Potential for more than minimal harm
2021-06-16
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-08-23
F · Potential for more than minimal harm
2021-06-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-07-14
F · Potential for more than minimal harm
2021-06-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-08-23
F · Potential for more than minimal harm
2021-06-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-08-23
F · Potential for more than minimal harm
2021-06-16
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2021-08-23
F · Potential for more than minimal harm
2021-06-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-08-23
F · Potential for more than minimal harm
2021-06-16
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2021-08-23
F · Potential for more than minimal harm
2021-06-16
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-08-23
F · Potential for more than minimal harm
2021-06-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-08-23
F · Potential for more than minimal harm
2021-06-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-08-23
E · Potential for more than minimal harm
2021-06-16
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2021-08-23
E · Potential for more than minimal harm
2021-06-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-08-23
E · Potential for more than minimal harm
2021-06-16
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2021-08-23
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-01-23
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-03-07
E · Potential for more than minimal harm
2025-01-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-23
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-23
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-07
G · Actual harm
2023-11-15
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-12-22
J · Immediate jeopardy
2023-05-31
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-24
D · Potential for more than minimal harm
2023-04-24
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-04-24
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-04-24
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2023-05-31
F · Potential for more than minimal harm
2023-01-23
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-02-21
F · Potential for more than minimal harm
2023-01-23
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-02-21
F · Potential for more than minimal harm
2023-01-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-02-21
F · Potential for more than minimal harm
2023-01-23
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-02-21
E · Potential for more than minimal harm
2023-01-23
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-02-21
E · Potential for more than minimal harm
2023-01-23
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-23
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-23
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-23
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-23
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-23
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-23
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-23
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-23
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-23
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-23
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-23
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-23
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-02-21
D · Potential for more than minimal harm
2021-06-16
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2021-07-12
D · Potential for more than minimal harm
2021-06-16
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-07-12
D · Potential for more than minimal harm
2021-06-16
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2021-07-12
D · Potential for more than minimal harm
2021-06-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-07-12
D · Potential for more than minimal harm
2021-06-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-07-12
D · Potential for more than minimal harm
2021-06-16
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-07-12
Penalties and ownership
What sits behind the stars
$30,566
2023-11-15
Fine
Fine · fine $30,566
Fine
$0
2023-11-15
Payment Denial
Payment Denial · denial start 2023-12-12 · 10 days
10 day denial
$8,193
2023-04-24
Fine
Fine · fine $8,193
Fine
Ownership
Mccue, Tamara
Operational/Managerial Control · Individual
New Paradigm Solutions Inc
Operational/Managerial Control · Organization
Novotny, Michelle
Operational/Managerial Control · Individual
Novotny, William
Operational/Managerial Control · Individual
Ritchey, Olga
Operational/Managerial Control · Individual
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