Cycle 1
Health 2025-02-11 · Fire 2025-02-11
25 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Wichita, KS
Great Plains Post Acute
1-star overall rating with 1-star inspections with Special Focus status with $49,505 in total fines with 23 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
7101 E 21st Street North, Wichita, KS
(316) 867-6101
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
118
Certified beds
Average residents
108
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1988-01-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 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
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
86%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
74%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,314
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.44
Composite VBP score used to determine payment impact.
Payment multiplier
0.9934
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.34
Performance 18.03% · Measure score 7.34 · Achievement 7.34 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
6.54
Baseline 7.01% · Performance 5.88% · Measure score 6.54 · Achievement 6.54 · Improvement 5.11
Total nurse turnover
0
Baseline 58.24% · Performance 68.07% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.30
Baseline 3.28 hours · Performance 3.73 hours · Measure score 2.30 · Achievement 2.30 · Improvement 1.31
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.28% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 65 · Observed rate 6.15% · Lower 95% interval 6.62% |
| Discharge to community | 40.24% |
50.57%
10.3 pts worse
|
No Different than the National Rate · Eligible stays 43 · Observed rate 27.91% · Lower 95% interval 29.48% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 37 · Denominator 37 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 37 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 15 · 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 37 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.88% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 0% · Lower 95% interval 3.3% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 124 |
| Staff flu vaccination coverage | 66.37% |
42%
24.4 pts better
|
Numerator 150 · Denominator 226 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · 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 2.5 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
2.2
0.5 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.9 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 34.4% |
91.8%
57.4 pts worse
|
93.4%
59 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 27.7% · Q3 41.5% · Q4 39.4% · 4Q avg 34.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 59.6% |
95.5%
35.9 pts worse
|
95.5%
35.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 59.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
4.4%
1.9 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.0% · Q3 1.9% · Q4 1.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.6%
5.6 pts better
|
11.4%
11.4 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 who lose too much weight | 6.0% |
5.0%
1 pts worse
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 7.5% · Q3 8.9% · Q4 2.1% · 4Q avg 6.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.5% |
23.2%
3.7 pts better
|
19.6%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 17.0% · Q3 20.8% · Q4 19.2% · 4Q avg 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.6% |
19.8%
0.2 pts better
|
16.7%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 20.0% · Q3 20.0% · Q4 20.6% · 4Q avg 19.6% · 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 | 13.7% |
18.4%
4.7 pts better
|
16.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 13.0% · Q3 15.4% · Q4 11.9% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.4% |
18.8%
6.4 pts better
|
14.9%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 16.7% · Q3 9.4% · Q4 13.1% · 4Q avg 12.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.8%
1 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · 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 1.1% · Q2 4.0% · Q3 3.8% · Q4 2.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.1% |
23.2%
0.9 pts worse
|
19.8%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 30.9% · Q3 27.0% · Q4 16.5% · 4Q avg 24.1% |
| Percentage of long-stay residents with pressure ulcers | 8.6% |
4.6%
4 pts worse
|
5.1%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 10.0% · Q3 10.7% · Q4 3.4% · 4Q avg 8.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 38.4% |
75.6%
37.2 pts worse
|
81.7%
43.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 36.5% · Q2 30.4% · Q3 54.5% · 4Q avg 38.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.6% |
11.7%
4.1 pts better
|
12.0%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.6% · Observed 8.7% · Expected 12.8% · 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% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 47.8% |
73.5%
25.7 pts worse
|
79.7%
31.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 47.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.1% |
23.0%
4.1 pts worse
|
23.9%
3.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.1% · Observed 30.4% · Expected 26.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-29 · Fire 2023-06-29
24 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-04-21 · Fire 2022-04-21
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-11
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2025-04-23
F · Potential for more than minimal harm
2025-02-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-23
F · Potential for more than minimal harm
2025-02-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-05
F · Potential for more than minimal harm
2025-02-11
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-04-23
F · Potential for more than minimal harm
2025-02-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-23
F · Potential for more than minimal harm
2025-02-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-23
F · Potential for more than minimal harm
2025-02-11
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-04-23
F · Potential for more than minimal harm
2025-02-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-23
F · Potential for more than minimal harm
2025-02-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-23
F · Potential for more than minimal harm
2025-02-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-03-04
F · Potential for more than minimal harm
2025-02-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-05
F · Potential for more than minimal harm
2025-02-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-23
F · Potential for more than minimal harm
2025-02-11
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-03-05
E · Potential for more than minimal harm
2025-02-11
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2025-04-23
F · Potential for more than minimal harm
2023-06-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-25
F · Potential for more than minimal harm
2023-06-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-25
F · Potential for more than minimal harm
2023-06-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-06-29
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 2023-09-25
D · Potential for more than minimal harm
2023-06-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-25
F · Potential for more than minimal harm
2022-04-21
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 2022-07-08
F · Potential for more than minimal harm
2022-04-21
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 2022-07-08
F · Potential for more than minimal harm
2022-04-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-07-08
F · Potential for more than minimal harm
2022-04-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-08
F · Potential for more than minimal harm
2022-04-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-07-08
F · Potential for more than minimal harm
2022-04-21
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-06-08
F · Potential for more than minimal harm
2022-04-21
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-07-08
F · Potential for more than minimal harm
2022-04-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-07-08
F · Potential for more than minimal harm
2022-04-21
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 2022-07-08
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-15
J · Immediate jeopardy
2025-03-05
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2025-03-31
J · Immediate jeopardy
2025-03-05
F675 · Quality of Life and Care Deficiencies
Health
Honor each resident's preferences, choices, values and beliefs.
Corrected 2025-03-31
G · Actual harm
2025-02-11
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 2025-03-31
G · Actual harm
2025-02-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-31
G · Actual harm
2025-02-11
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 2025-03-31
G · Actual harm
2025-02-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-03-31
F · Potential for more than minimal harm
2025-02-11
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2025-03-31
F · Potential for more than minimal harm
2025-02-11
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 2025-03-31
F · Potential for more than minimal harm
2025-02-11
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-03-31
F · Potential for more than minimal harm
2025-02-11
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-03-31
F · Potential for more than minimal harm
2025-02-11
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 2025-03-31
F · Potential for more than minimal harm
2025-02-11
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-03-31
E · Potential for more than minimal harm
2025-02-11
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 2025-03-31
E · Potential for more than minimal harm
2025-02-11
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 2025-03-31
E · Potential for more than minimal harm
2025-02-11
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 2025-03-31
E · Potential for more than minimal harm
2025-02-11
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2025-03-31
E · Potential for more than minimal harm
2025-02-11
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 2025-03-31
D · Potential for more than minimal harm
2025-02-11
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 2025-03-31
D · Potential for more than minimal harm
2025-02-11
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 2025-03-31
D · Potential for more than minimal harm
2025-02-11
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-11
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 2025-03-31
D · Potential for more than minimal harm
2025-02-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-11
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-11
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-03-31
D · Potential for more than minimal harm
2024-06-24
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-06-24
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 2024-08-01
J · Immediate jeopardy
2023-12-21
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 2024-01-11
G · Actual harm
2023-06-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-28
G · Actual harm
2023-06-29
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-07-28
F · Potential for more than minimal harm
2023-06-29
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 2023-07-28
F · Potential for more than minimal harm
2023-06-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-28
E · Potential for more than minimal harm
2023-06-29
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 2023-07-28
D · Potential for more than minimal harm
2023-06-29
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 2023-07-28
D · Potential for more than minimal harm
2023-06-29
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-29
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-29
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 2023-07-28
D · Potential for more than minimal harm
2023-06-29
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 2023-07-28
D · Potential for more than minimal harm
2023-06-29
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 2023-07-28
D · Potential for more than minimal harm
2023-06-29
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 2023-07-28
D · Potential for more than minimal harm
2023-06-29
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 2023-07-28
D · Potential for more than minimal harm
2023-06-29
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 2023-07-28
D · Potential for more than minimal harm
2023-06-29
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 2023-07-28
D · Potential for more than minimal harm
2023-06-29
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 2023-07-28
D · Potential for more than minimal harm
2023-06-29
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-29
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 2023-07-28
D · Potential for more than minimal harm
2023-06-29
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-29
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 2023-07-28
D · Potential for more than minimal harm
2023-06-29
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-29
F775 · Administration Deficiencies
Health
Keep complete, dated laboratory records in the resident's record.
Corrected 2023-07-28
G · Actual harm
2022-04-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-05-18
D · Potential for more than minimal harm
2022-04-21
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 2022-05-18
D · Potential for more than minimal harm
2022-04-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-05-18
D · Potential for more than minimal harm
2022-04-21
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 2022-05-18
D · Potential for more than minimal harm
2022-04-21
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 2022-05-18
D · Potential for more than minimal harm
2022-04-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-18
D · Potential for more than minimal harm
2022-04-21
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-05-18
D · Potential for more than minimal harm
2022-04-21
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 2022-05-18
Penalties and ownership
What sits behind the stars
$27,967
2025-02-11
Fine
Fine · fine $27,967
Fine
$0
2025-02-11
Payment Denial
Payment Denial · denial start 2025-03-13 · 18 days
18 day denial
$14,518
2023-12-21
Fine
Fine · fine $14,518
Fine
$2,098
2023-09-11
Fine
Fine · fine $2,098
Fine
$1,748
2023-09-05
Fine
Fine · fine $1,748
Fine
$3,174
2023-08-14
Fine
Fine · fine $3,174
Fine
Ownership
Providence Group Nh, LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Operational/Managerial Control · Individual
Apt, Frederick
Corporate Officer · Individual
Banda, Ruben
Operational/Managerial Control · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Harper, Lauren
Operational/Managerial Control · Individual
Jergensen, Joshua
Operational/Managerial Control · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mccue, Tamara
Operational/Managerial Control · Individual
Mitchell, John
Operational/Managerial Control · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
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