Cycle 1
Health 2024-04-17 · Fire 2024-04-17
15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Atchison, KS
Atchison Senior Village Rehabilitation And Nursing
2-star overall rating with 2-star inspections with $20,817 in total fines with 15 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
1419 N 6th Street, Atchison, KS
(913) 367-1906
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
45
Certified beds
Average residents
47
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2013-03-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 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
0.43
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.06
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.13
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.62
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.12
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
3.46
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 50% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.4% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 0% · Lower 95% interval 6.2% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.78 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 92.86% |
95.27%
2.4 pts worse
|
Numerator 26 · Denominator 28 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 28 |
| Discharge self-care score | 45.45% |
53.69%
8.2 pts worse
|
Numerator 10 · Denominator 22 |
| Discharge mobility score | 54.55% |
50.94%
3.6 pts better
|
Numerator 12 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 3.57% |
2.29%
1.3 pts worse
|
Numerator 1 · Denominator 28 · Adjusted rate 4.29% |
| 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 68 |
| Staff flu vaccination coverage | 35.05% |
42%
7 pts worse
|
Numerator 34 · Denominator 97 |
| Discharge function score | 63.64% |
56.45%
7.2 pts better
|
Numerator 14 · Denominator 22 |
| 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 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · 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 | 2.0 |
1.8
0.2 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.1 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.6 |
2.2
1.4 pts worse
|
1.8
1.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.6 · Observed 3.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.2% |
91.8%
1.4 pts better
|
93.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 94.4% · Q2 89.7% · Q3 94.1% · Q4 94.6% · 4Q avg 93.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 71.4% |
95.5%
24.1 pts worse
|
95.5%
24.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 71.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
4.4%
2.3 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 5.1% · Q3 0.0% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 18.5% |
5.6%
12.9 pts worse
|
11.4%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.8% · Q3 12.9% · Q4 50.0% · 4Q avg 18.5% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
5.0%
2 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 5.4% · Q3 0.0% · Q4 0.0% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 37.5% |
23.2%
14.3 pts worse
|
19.6%
17.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.3% · Q2 37.8% · Q3 40.6% · Q4 36.4% · 4Q avg 37.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.9% |
19.8%
2.1 pts worse
|
16.7%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 18.5% · Q3 16.7% · Q4 27.6% · 4Q avg 21.9% · 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 | 13.4% |
18.4%
5 pts better
|
16.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 29.1% · Q2 13.3% · Q3 12.5% · Q4 0.0% · 4Q avg 13.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.9% |
18.8%
9.9 pts better
|
14.9%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 8.3% · Q3 12.5% · Q4 6.1% · 4Q avg 8.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.8%
1.8 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
3.1%
3.1 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.1% |
23.2%
1.9 pts worse
|
19.8%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 28.3% · Q3 19.0% · Q4 27.0% · 4Q avg 25.1% |
| Percentage of long-stay residents with pressure ulcers | 6.1% |
4.6%
1.5 pts worse
|
5.1%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 6.3% · Q3 3.4% · Q4 3.4% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 54.0% |
75.6%
21.6 pts worse
|
81.7%
27.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 35.0% · Q3 67.6% · Q4 62.1% · 4Q avg 54.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.5% |
11.7%
7.8 pts worse
|
12.0%
7.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.5% · Observed 20.7% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 8.2% |
2.2%
6 pts worse
|
1.6%
6.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 10.0% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 25.0% |
73.5%
48.5 pts worse
|
79.7%
54.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 25.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.3% |
23.0%
10.7 pts better
|
23.9%
11.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.3% · Observed 10.3% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-02 · Fire 2022-11-02
20 health deficiencies
Top issue: Administration (4 deficiencies)
17 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Cycle 3
Health 2021-06-03 · Fire 2021-06-03
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
16 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-17
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-06-13
F · Potential for more than minimal harm
2024-04-17
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-06-13
F · Potential for more than minimal harm
2024-04-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-13
F · Potential for more than minimal harm
2024-04-17
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 2024-06-13
F · Potential for more than minimal harm
2024-04-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-13
F · Potential for more than minimal harm
2024-04-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-13
E · Potential for more than minimal harm
2024-04-17
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-06-13
E · Potential for more than minimal harm
2024-04-17
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-06-13
E · Potential for more than minimal harm
2024-04-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-04-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-06-13
F · Potential for more than minimal harm
2022-11-02
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-01-10
F · Potential for more than minimal harm
2022-11-02
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-01-10
F · Potential for more than minimal harm
2022-11-02
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-01-10
F · Potential for more than minimal harm
2022-11-02
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-01-10
F · Potential for more than minimal harm
2022-11-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-10
F · Potential for more than minimal harm
2022-11-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-10
F · Potential for more than minimal harm
2022-11-02
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-01-10
F · Potential for more than minimal harm
2022-11-02
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-01-10
F · Potential for more than minimal harm
2022-11-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-10
F · Potential for more than minimal harm
2022-11-02
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2023-01-10
F · Potential for more than minimal harm
2022-11-02
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 2023-01-10
E · Potential for more than minimal harm
2022-11-02
K163 · Construction Deficiencies
Fire Safety
Install noncombustible or limited-combustible interior walls.
Corrected 2023-01-10
E · Potential for more than minimal harm
2022-11-02
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-01-10
E · Potential for more than minimal harm
2022-11-02
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-01-10
E · Potential for more than minimal harm
2022-11-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-10
E · Potential for more than minimal harm
2022-11-02
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-01-10
E · Potential for more than minimal harm
2022-11-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-10
F · Potential for more than minimal harm
2021-06-03
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2021-08-20
F · Potential for more than minimal harm
2021-06-03
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 2021-08-20
F · Potential for more than minimal harm
2021-06-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-08-20
F · Potential for more than minimal harm
2021-06-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-08-20
F · Potential for more than minimal harm
2021-06-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-08-20
F · Potential for more than minimal harm
2021-06-03
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2021-08-20
F · Potential for more than minimal harm
2021-06-03
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-08-20
F · Potential for more than minimal harm
2021-06-03
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2021-08-20
F · Potential for more than minimal harm
2021-06-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-08-20
F · Potential for more than minimal harm
2021-06-03
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 2021-08-20
F · Potential for more than minimal harm
2021-06-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-08-20
E · Potential for more than minimal harm
2021-06-03
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2021-08-20
E · Potential for more than minimal harm
2021-06-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-08-20
E · Potential for more than minimal harm
2021-06-03
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-08-20
E · Potential for more than minimal harm
2021-06-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-08-20
D · Potential for more than minimal harm
2021-06-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-08-20
Inspection history
Recent health citations
J · Immediate jeopardy
2024-10-21
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 2024-10-16
F · Potential for more than minimal harm
2024-04-17
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-04-17
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-04-17
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-04-17
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 2024-05-17
E · Potential for more than minimal harm
2024-04-17
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 2024-05-17
E · Potential for more than minimal harm
2024-04-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-17
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 2024-05-17
D · Potential for more than minimal harm
2024-04-17
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-17
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-17
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-17
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 2024-05-17
D · Potential for more than minimal harm
2024-04-17
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 2024-05-17
D · Potential for more than minimal harm
2024-04-17
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 2024-05-17
F · Potential for more than minimal harm
2022-11-02
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2022-12-16
F · Potential for more than minimal harm
2022-11-02
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2022-12-16
F · Potential for more than minimal harm
2022-11-02
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2022-12-16
F · Potential for more than minimal harm
2022-11-02
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-12-16
F · Potential for more than minimal harm
2022-11-02
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2022-12-16
F · Potential for more than minimal harm
2022-11-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-16
F · Potential for more than minimal harm
2022-11-02
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-12-16
F · Potential for more than minimal harm
2022-11-02
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 2022-12-16
E · Potential for more than minimal harm
2022-11-02
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-12-16
E · Potential for more than minimal harm
2022-11-02
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 2022-12-16
E · Potential for more than minimal harm
2022-11-02
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 2022-12-16
D · Potential for more than minimal harm
2022-11-02
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 2022-12-16
D · Potential for more than minimal harm
2022-11-02
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-11-02
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 2022-12-16
D · Potential for more than minimal harm
2022-11-02
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 2022-12-16
D · Potential for more than minimal harm
2022-11-02
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 2022-12-16
D · Potential for more than minimal harm
2022-11-02
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 2022-12-16
C · Minimal harm
2022-11-02
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-12-16
C · Minimal harm
2022-11-02
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2022-12-16
F · Potential for more than minimal harm
2021-06-03
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 2021-06-30
E · Potential for more than minimal harm
2021-06-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-06-30
Penalties and ownership
What sits behind the stars
$8,021
2024-10-21
Fine
Fine · fine $8,021
Fine
$3,764
2024-02-20
Fine
Fine · fine $3,764
Fine
$9,032
2024-01-30
Fine
Fine · fine $9,032
Fine
Ownership
Gateway Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Burton, Spencer
Corporate Director · Individual
Fitch, Craig
Corporate Officer · Individual
Groth, Mcgarrett
Contracted Managing Employee · Individual
Lewis, Corwin
Corporate Officer · Individual
Munford, Elizabeth
Operational/Managerial Control · Individual
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