Cycle 1
Health 2024-06-03 · Fire 2024-06-03
31 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (6 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Clearwater, KS
Clearwater Nursing & Rehabilitation Center
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $214,803 in total fines with 31 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
620 E Wood Street, Clearwater, KS
(620) 584-2271
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
55
Certified beds
Average residents
44
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Advena Living Communities
Operator or chain grouping
Approved since
2002-05-02
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
0.30
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.51
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.50
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
0.99
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.95
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.33
CMS adjusted RN staffing hours
Adjusted total hours
3.89
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
80%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
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
0
Performance 80.00% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.35 hours · Performance 2.90 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.19% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 45 · Observed rate 11.11% · Lower 95% interval 7.04% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.76 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 32 · Denominator 32 |
| Falls with major injury | 3.13% |
0.77%
2.4 pts worse
|
Numerator 1 · Denominator 32 |
| Discharge self-care score | 20.69% |
53.69%
33 pts worse
|
Numerator 6 · Denominator 29 |
| Discharge mobility score | 34.48% |
50.94%
16.5 pts worse
|
Numerator 10 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 3.13% |
2.29%
0.8 pts worse
|
Numerator 1 · Denominator 32 · Adjusted rate 2.57% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · 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 43 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 34.48% |
56.45%
22 pts worse
|
Numerator 10 · Denominator 29 |
| 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 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · 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 | 2.7 |
1.8
0.9 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.5 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
2.2
0.2 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.6 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
91.8%
6.9 pts better
|
93.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.4% · Q3 97.5% · Q4 100.0% · 4Q avg 98.7% |
| 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 | 3.8% |
4.4%
0.6 pts better
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 2.6% · Q3 5.0% · Q4 2.8% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
5.6%
4.3 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 0.9% |
5.0%
4.1 pts better
|
5.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.3% |
23.2%
1.9 pts better
|
19.6%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 17.2% · Q3 22.2% · Q4 25.0% · 4Q avg 21.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.3% |
19.8%
7.5 pts worse
|
16.7%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 25.0% · Q3 32.0% · Q4 33.3% · 4Q avg 27.3% · 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 | 22.7% |
18.4%
4.3 pts worse
|
16.3%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.8% |
18.8%
4 pts better
|
14.9%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 3.4% · Q3 32.4% · Q4 13.3% · 4Q avg 14.8% · 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 | 2.7% |
3.1%
0.4 pts better
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.9% · Q3 5.3% · Q4 0.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.4% |
23.2%
0.2 pts worse
|
19.8%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 26.6% · Q3 20.1% · Q4 32.3% · 4Q avg 23.4% |
| Percentage of long-stay residents with pressure ulcers | 1.4% |
4.6%
3.2 pts better
|
5.1%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 3.2% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.0% |
75.6%
10.4 pts better
|
81.7%
4.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 80.0% · Q3 95.7% · Q4 97.1% · 4Q avg 86.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.6% |
11.7%
0.1 pts better
|
12.0%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.6% · Observed 12.5% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 8.0% |
2.2%
5.8 pts worse
|
1.6%
6.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 8.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 70.4% |
73.5%
3.1 pts worse
|
79.7%
9.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 70.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.2% |
23.0%
3.8 pts better
|
23.9%
4.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.2% · Observed 20.8% · Expected 25.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-08 · Fire 2022-11-08
13 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
19 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2021-04-05 · Fire 2021-04-05
30 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-03
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-07-25
F · Potential for more than minimal harm
2024-06-03
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 2024-08-06
F · Potential for more than minimal harm
2024-06-03
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2024-07-25
F · Potential for more than minimal harm
2024-06-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-24
F · Potential for more than minimal harm
2024-06-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-06-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-07-25
F · Potential for more than minimal harm
2024-06-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-07-19
F · Potential for more than minimal harm
2024-06-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-06-03
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 2024-08-06
F · Potential for more than minimal harm
2024-06-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-06-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-06-03
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-07-19
F · Potential for more than minimal harm
2022-11-08
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-01-18
F · Potential for more than minimal harm
2022-11-08
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-01-18
F · Potential for more than minimal harm
2022-11-08
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-01-18
F · Potential for more than minimal harm
2022-11-08
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-01-18
F · Potential for more than minimal harm
2022-11-08
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-01-18
F · Potential for more than minimal harm
2022-11-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-18
F · Potential for more than minimal harm
2022-11-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-18
F · Potential for more than minimal harm
2022-11-08
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-01-18
F · Potential for more than minimal harm
2022-11-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-01-18
F · Potential for more than minimal harm
2022-11-08
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-01-18
F · Potential for more than minimal harm
2022-11-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-18
F · Potential for more than minimal harm
2022-11-08
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-01-18
F · Potential for more than minimal harm
2022-11-08
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 2023-01-18
F · Potential for more than minimal harm
2022-11-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-18
F · Potential for more than minimal harm
2022-11-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-18
E · Potential for more than minimal harm
2022-11-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-01-18
E · Potential for more than minimal harm
2022-11-08
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 2023-01-18
E · Potential for more than minimal harm
2022-11-08
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 2023-01-18
D · Potential for more than minimal harm
2022-11-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-01-18
F · Potential for more than minimal harm
2021-04-05
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 2021-05-25
F · Potential for more than minimal harm
2021-04-05
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2021-05-25
E · Potential for more than minimal harm
2021-04-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-05-25
E · Potential for more than minimal harm
2021-04-05
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-05-25
E · Potential for more than minimal harm
2021-04-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-05-25
Inspection history
Recent health citations
J · Immediate jeopardy
2025-09-17
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 2025-10-13
D · Potential for more than minimal harm
2025-09-17
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-10-13
D · Potential for more than minimal harm
2025-09-17
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 2025-10-13
D · Potential for more than minimal harm
2025-09-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-10-13
J · Immediate jeopardy
2025-01-14
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 2024-12-18
L · Immediate jeopardy
2024-06-03
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 2024-07-01
L · Immediate jeopardy
2024-06-03
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 2024-07-01
L · Immediate jeopardy
2024-06-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-07-01
K · Immediate jeopardy
2024-06-03
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 2024-07-01
G · Actual harm
2024-06-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-01
F · Potential for more than minimal harm
2024-06-03
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 2024-07-01
F · Potential for more than minimal harm
2024-06-03
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-07-01
F · Potential for more than minimal harm
2024-06-03
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 2024-07-01
F · Potential for more than minimal harm
2024-06-03
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-07-01
F · Potential for more than minimal harm
2024-06-03
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 2024-07-01
F · Potential for more than minimal harm
2024-06-03
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-07-01
F · Potential for more than minimal harm
2024-06-03
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-07-01
F · Potential for more than minimal harm
2024-06-03
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 2024-07-01
F · Potential for more than minimal harm
2024-06-03
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-07-01
F · Potential for more than minimal harm
2024-06-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-01
E · Potential for more than minimal harm
2024-06-03
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 2024-07-01
E · Potential for more than minimal harm
2024-06-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-01
E · Potential for more than minimal harm
2024-06-03
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 2024-07-01
D · Potential for more than minimal harm
2024-06-03
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-06-03
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-06-03
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 2024-07-01
D · Potential for more than minimal harm
2024-06-03
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 2024-07-01
D · Potential for more than minimal harm
2024-06-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-06-03
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-06-03
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-06-03
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 2024-07-01
D · Potential for more than minimal harm
2024-06-03
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 2024-07-01
D · Potential for more than minimal harm
2023-06-21
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 2023-08-04
G · Actual harm
2022-11-08
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-12-10
F · Potential for more than minimal harm
2022-11-08
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 2022-12-10
D · Potential for more than minimal harm
2022-11-08
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-12-10
D · Potential for more than minimal harm
2022-11-08
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-12-10
D · Potential for more than minimal harm
2022-11-08
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2022-12-10
D · Potential for more than minimal harm
2022-11-08
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 2022-12-10
D · Potential for more than minimal harm
2022-11-08
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 2022-12-10
D · Potential for more than minimal harm
2022-11-08
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 2022-12-10
D · Potential for more than minimal harm
2022-11-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-12-10
D · Potential for more than minimal harm
2022-11-08
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 2022-12-10
D · Potential for more than minimal harm
2022-11-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-10
D · Potential for more than minimal harm
2022-11-08
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 2022-12-10
J · Immediate jeopardy
2021-04-05
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2021-05-10
G · Actual harm
2021-04-05
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2021-05-10
G · Actual harm
2021-04-05
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 2021-05-10
F · Potential for more than minimal harm
2021-04-05
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 2021-05-10
F · Potential for more than minimal harm
2021-04-05
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2021-05-10
F · Potential for more than minimal harm
2021-04-05
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2021-05-10
F · Potential for more than minimal harm
2021-04-05
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2021-05-10
F · Potential for more than minimal harm
2021-04-05
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2021-05-10
E · Potential for more than minimal harm
2021-04-05
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2021-05-03
E · Potential for more than minimal harm
2021-04-05
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2021-05-03
E · Potential for more than minimal harm
2021-04-05
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2021-05-03
E · Potential for more than minimal harm
2021-04-05
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 2021-05-10
E · Potential for more than minimal harm
2021-04-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-05-10
E · Potential for more than minimal harm
2021-04-05
F741 · Quality of Life and Care Deficiencies
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2021-05-10
E · Potential for more than minimal harm
2021-04-05
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-05-10
E · Potential for more than minimal harm
2021-04-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-05-10
D · Potential for more than minimal harm
2021-04-05
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2021-05-03
D · Potential for more than minimal harm
2021-04-05
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 2021-05-10
D · Potential for more than minimal harm
2021-04-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2021-05-10
D · Potential for more than minimal harm
2021-04-05
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2021-05-10
D · Potential for more than minimal harm
2021-04-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-05-10
D · Potential for more than minimal harm
2021-04-05
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 2021-05-10
D · Potential for more than minimal harm
2021-04-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-05-10
D · Potential for more than minimal harm
2021-04-05
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 2021-05-10
D · Potential for more than minimal harm
2021-04-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-05-10
D · Potential for more than minimal harm
2021-04-05
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-05-10
D · Potential for more than minimal harm
2021-04-05
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 2021-05-10
D · Potential for more than minimal harm
2021-04-05
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 2021-05-10
D · Potential for more than minimal harm
2021-04-05
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 2021-05-10
Penalties and ownership
What sits behind the stars
$25,825
2025-09-17
Fine
Fine · fine $25,825
Fine
$18,213
2025-01-14
Fine
Fine · fine $18,213
Fine
$170,765
2024-06-03
Fine
Fine · fine $170,765
Fine
Ownership
Ks Host Portfolio Opco LLC
5% Or Greater Direct Ownership Interest · Organization
Cghii Inc
5% Or Greater Indirect Ownership Interest · Organization
Cornerstone Group Holdings Inc
5% Or Greater Indirect Ownership Interest · Organization
Genuth, Mike
5% Or Greater Indirect Ownership Interest · Individual
Greenfield, Michael
5% Or Greater Indirect Ownership Interest · Individual
Mccue, Tamara
Operational/Managerial Control · Individual
Mgmg Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Novotny, Michelle
5% Or Greater Indirect Ownership Interest · Individual
Novotny, Michelle
Operational/Managerial Control · Individual
Novotny, William
5% Or Greater Indirect Ownership Interest · Individual
Novotny, William
Operational/Managerial Control · Individual
Reddig, Ashley
Operational/Managerial Control · Individual
Nearby options
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Diversicare Of Haysville
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#2
Rolling Hills Health And Rehab
Wichita, KS
3-star overall rating with 3-star inspections with $39,118 in total fines with 10 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Medicalodges Goddard
Goddard, KS
3-star overall rating with 2-star inspections with $10,059 in total fines with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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