Cycle 1
Health 2025-07-29 · Fire 2023-11-07
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Great Bend, KS
Azria Health Great Bend
1-star overall rating with 2-star inspections with $69,170 in total fines with 14 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
1560 K 96 Hwy, Great Bend, KS
(620) 792-2448
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
85
Certified beds
Average residents
59
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Azria Health
Operator or chain grouping
Approved since
1994-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 1 overall / 2 health / 3 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
0.66
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.49
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.70
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.85
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.15
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.46
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
3.96
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,192
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.54
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
5.89
Baseline 19.68% · Performance 18.70% · Measure score 5.89 · Achievement 5.89 · Improvement 3.20
Healthcare-associated infections
0
Baseline 7.29% · Performance 7.86% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.57
Baseline 40.82% · Performance 49.09% · Measure score 3.57 · Achievement 3.57 · Improvement 0
Adjusted total nurse staffing
1.55
Baseline 3.75 hours · Performance 3.52 hours · Measure score 1.55 · Achievement 1.55 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.23% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 88 · Observed rate 9.09% · Lower 95% interval 7.39% |
| Discharge to community | 46.43% |
50.57%
4.1 pts worse
|
No Different than the National Rate · Eligible stays 75 · Observed rate 40% · Lower 95% interval 35.3% |
| Medicare spending per beneficiary | 1.27 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 82 · Denominator 82 |
| Falls with major injury | 2.44% |
0.77%
1.7 pts worse
|
Numerator 2 · Denominator 82 |
| Discharge self-care score | 55.77% |
53.69%
2.1 pts better
|
Numerator 29 · Denominator 52 |
| Discharge mobility score | 42.31% |
50.94%
8.6 pts worse
|
Numerator 22 · Denominator 52 |
| Pressure ulcers or injuries, new or worsened | 2.44% |
2.29%
0.1 pts worse
|
Numerator 2 · Denominator 82 · Adjusted rate 2.81% |
| Healthcare-associated infections requiring hospitalization | 7.86% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 10.34% · Lower 95% interval 4.43% |
| Staff COVID-19 vaccination coverage | 1.98% |
8.2%
6.2 pts worse
|
Numerator 2 · Denominator 101 |
| Staff flu vaccination coverage | 29.79% |
42%
12.2 pts worse
|
Numerator 28 · Denominator 94 |
| Discharge function score | 57.69% |
56.45%
1.2 pts better
|
Numerator 30 · Denominator 52 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 27 · Denominator 27 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 21 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 27.78% |
25.2%
2.6 pts better
|
Numerator 15 · Denominator 54 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.8
0.4 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.7 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.0 |
2.2
1.8 pts worse
|
1.8
2.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.0 · Observed 4.4 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
91.8%
7.8 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.5%
4.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.4% |
4.4%
3 pts worse
|
3.3%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 7.9% · Q3 9.5% · Q4 5.4% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.7% |
5.6%
3.1 pts worse
|
11.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 12.5% · Q3 0.0% · Q4 8.3% · 4Q avg 8.7% |
| Percentage of long-stay residents who lose too much weight | 6.8% |
5.0%
1.8 pts worse
|
5.4%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 8.0% · Q3 8.7% · Q4 4.7% · 4Q avg 6.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.1% |
23.2%
0.1 pts better
|
19.6%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 28.6% · Q3 21.6% · Q4 21.3% · 4Q avg 23.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.3% |
19.8%
6.5 pts better
|
16.7%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 16.7% · Q3 12.2% · Q4 10.3% · 4Q avg 13.3% · 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 | 36.7% |
18.4%
18.3 pts worse
|
16.3%
20.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 36.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.7% |
18.8%
1.9 pts worse
|
14.9%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 38.2% · Q3 20.0% · Q4 8.9% · 4Q avg 20.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 7.7% |
1.8%
5.9 pts worse
|
1.0%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 11.3% · Q3 6.2% · Q4 7.7% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.3% |
3.1%
2.2 pts worse
|
1.7%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 10.5% · Q3 6.9% · Q4 1.9% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.0% |
23.2%
2.2 pts better
|
19.8%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 40.4% · Q3 8.1% · Q4 12.0% · 4Q avg 21.0% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
4.6%
1.3 pts worse
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 4.6% · Q3 8.2% · Q4 7.9% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.4% |
75.6%
19.8 pts better
|
81.7%
13.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.1% · Q2 96.2% · Q3 98.0% · Q4 95.8% · 4Q avg 95.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 24.0% |
11.7%
12.3 pts worse
|
12.0%
12 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.0% · Observed 25.9% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.4% |
73.5%
20.9 pts better
|
79.7%
14.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.5% |
23.0%
0.5 pts worse
|
23.9%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.5% · Observed 25.9% · Expected 26.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-07 · Fire 2022-04-05
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2022-04-05 · Fire 2020-11-24
13 health deficiencies
Top issue: Pharmacy Service (6 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-11-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-01-18
F · Potential for more than minimal harm
2023-11-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-18
F · Potential for more than minimal harm
2023-11-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-01-18
F · Potential for more than minimal harm
2023-11-07
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-01-18
F · Potential for more than minimal harm
2023-11-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-01-18
E · Potential for more than minimal harm
2023-11-07
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 2024-01-18
D · Potential for more than minimal harm
2023-11-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-01-18
L · Immediate jeopardy
2022-04-05
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 2022-06-06
F · Potential for more than minimal harm
2022-04-05
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 2022-06-06
F · Potential for more than minimal harm
2022-04-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-06-06
F · Potential for more than minimal harm
2022-04-05
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2022-06-06
F · Potential for more than minimal harm
2022-04-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-06-06
F · Potential for more than minimal harm
2022-04-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-06-06
F · Potential for more than minimal harm
2022-04-05
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-05-10
F · Potential for more than minimal harm
2022-04-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-06-06
F · Potential for more than minimal harm
2022-04-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-06-06
E · Potential for more than minimal harm
2022-04-05
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-06-06
E · Potential for more than minimal harm
2022-04-05
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-06-06
E · Potential for more than minimal harm
2022-04-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-06-06
E · Potential for more than minimal harm
2022-04-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-06-06
D · Potential for more than minimal harm
2022-04-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-06-06
F · Potential for more than minimal harm
2020-11-24
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-01-27
F · Potential for more than minimal harm
2020-11-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-01-27
F · Potential for more than minimal harm
2020-11-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-01-27
E · Potential for more than minimal harm
2020-11-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-01-27
E · Potential for more than minimal harm
2020-11-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-01-27
Inspection history
Recent health citations
J · Immediate jeopardy
2025-07-29
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 2025-07-25
F · Potential for more than minimal harm
2025-07-29
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 2025-09-03
F · Potential for more than minimal harm
2025-07-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-03
E · Potential for more than minimal harm
2025-07-29
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 2025-09-03
D · Potential for more than minimal harm
2025-07-29
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-07-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-07-29
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-07-29
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 2025-09-03
D · Potential for more than minimal harm
2025-07-29
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-07-29
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-07-29
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-07-29
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 2025-09-03
C · Minimal harm
2025-07-29
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 2025-09-03
G · Actual harm
2025-05-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-23
J · Immediate jeopardy
2024-06-17
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 2024-06-13
G · Actual harm
2024-01-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-12-21
F · Potential for more than minimal harm
2023-11-07
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-12-22
E · Potential for more than minimal harm
2023-11-07
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 2023-12-22
D · Potential for more than minimal harm
2023-11-07
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 2023-12-22
D · Potential for more than minimal harm
2023-11-07
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 2023-12-22
C · Minimal harm
2023-11-07
F620 · Resident Rights Deficiencies
Health
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
Corrected 2023-12-22
E · Potential for more than minimal harm
2022-04-05
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-05-02
D · Potential for more than minimal harm
2022-04-05
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 2022-05-02
D · Potential for more than minimal harm
2022-04-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-05-02
D · Potential for more than minimal harm
2022-04-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-05-02
D · Potential for more than minimal harm
2022-04-05
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-05-02
D · Potential for more than minimal harm
2022-04-05
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-05-02
D · Potential for more than minimal harm
2022-04-05
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 2022-05-02
D · Potential for more than minimal harm
2022-04-05
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 2022-05-02
D · Potential for more than minimal harm
2022-04-05
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-05-02
D · Potential for more than minimal harm
2022-04-05
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 2022-05-02
D · Potential for more than minimal harm
2022-04-05
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 2022-05-02
D · Potential for more than minimal harm
2022-04-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-02
Penalties and ownership
What sits behind the stars
$26,685
2025-07-29
Fine
Fine · fine $26,685
Fine
$17,732
2025-05-07
Fine
Fine · fine $17,732
Fine
$9,315
2024-06-17
Fine
Fine · fine $9,315
Fine
$15,438
2023-11-07
Fine
Fine · fine $15,438
Fine
Ownership
Azg Opco Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Azg Opco Holdings LLC
Operational/Managerial Control · Organization
Azria Ventures LLC
5% Or Greater Indirect Ownership Interest · Organization
Azria Ventures LLC
Operational/Managerial Control · Organization
Hornung, Steven
5% Or Greater Indirect Ownership Interest · Individual
Hornung, Steven
Operational/Managerial Control · Individual
Hornung, Steven
Corporate Officer · Individual
Kaminer, Aaron
5% Or Greater Indirect Ownership Interest · Individual
Kaminer, Aaron
Operational/Managerial Control · Individual
Kaminer, Aaron
Corporate Officer · Individual
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