Cycle 1
Health 2025-05-22 · Fire 2025-05-22
10 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Oskaloosa, KS
Heritage Gardens Health And Rehabilitation Center
3-star overall rating with 3-star inspections with $13,056 in total fines with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
700 Cherokee, Oskaloosa, KS
(785) 863-2108
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
53
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Recover-Care Healthcare
Operator or chain grouping
Approved since
1994-11-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
25 facilities
Chain averages 3 overall / 2 health / 2 staffing / 3 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
0.49
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.42
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.62
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.20
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.38
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.47
CMS adjusted RN staffing hours
Adjusted total hours
3.45
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,473
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.56
Composite VBP score used to determine payment impact.
Payment multiplier
0.9832
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.15% · Performance 21.20% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.15
Baseline 6.54% · Performance 7.49% · Measure score 1.15 · Achievement 1.15 · Improvement 0
Total nurse turnover
5.22
Baseline 85.91% · Performance 50.98% · Measure score 5.22 · Achievement 3.11 · Improvement 5.22
Adjusted total nurse staffing
3.06
Baseline 3.50 hours · Performance 3.95 hours · Measure score 3.06 · Achievement 3.06 · Improvement 1.45
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.01% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 12.77% · Lower 95% interval 7.3% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.06% |
95.27%
1.8 pts better
|
Numerator 33 · Denominator 34 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 34 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 2.94% |
2.29%
0.6 pts worse
|
Numerator 1 · Denominator 34 · Adjusted rate 2.76% |
| Healthcare-associated infections requiring hospitalization | 7.49% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 34 · Observed rate 8.82% · Lower 95% interval 3.7% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 75 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · 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 | 2.2 |
1.8
0.4 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.5 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.6 |
2.2
1.4 pts worse
|
1.8
1.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.6 · Observed 3.9 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.2% |
91.8%
0.6 pts worse
|
93.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 90.0% · Q2 90.2% · Q3 92.3% · Q4 92.2% · 4Q avg 91.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.7% |
95.5%
4.8 pts worse
|
95.5%
4.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
4.4%
1 pts better
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 3.9% · Q3 1.9% · Q4 2.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
5.6%
4.9 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 1.7% |
5.0%
3.3 pts better
|
5.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.3% · Q3 0.0% · Q4 2.2% · 4Q avg 1.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 40.0% |
23.2%
16.8 pts worse
|
19.6%
20.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.0% · Q2 39.6% · Q3 37.3% · Q4 46.0% · 4Q avg 40.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.2% |
19.8%
3.6 pts better
|
16.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 17.2% · Q3 19.4% · Q4 6.2% · 4Q avg 16.2% · 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 | 11.1% |
18.4%
7.3 pts better
|
16.3%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 11.6% · 4Q avg 11.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.1% |
18.8%
8.3 pts worse
|
14.9%
12.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 25.0% · Q3 28.2% · Q4 31.0% · 4Q avg 27.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.8%
1.8 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
3.1%
3.1 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.9% |
23.2%
2.3 pts better
|
19.8%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 14.7% · Q3 23.8% · Q4 17.3% · 4Q avg 20.9% |
| Percentage of long-stay residents with pressure ulcers | 1.7% |
4.6%
2.9 pts better
|
5.1%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 2.3% · Q4 2.1% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 47.7% |
75.6%
27.9 pts worse
|
81.7%
34 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 47.6% · Q2 41.4% · Q3 54.5% · 4Q avg 47.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.6% |
11.7%
8.9 pts worse
|
12.0%
8.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.6% · Observed 22.9% · Expected 12.4% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 33.3% |
73.5%
40.2 pts worse
|
79.7%
46.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 33.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.8% |
23.0%
0.8 pts worse
|
23.9%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.8% · Observed 31.4% · Expected 31.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-20 · Fire 2023-09-20
14 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Cycle 3
Health 2022-01-27 · Fire 2022-01-27
20 health deficiencies
Top issue: Resident Rights (6 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-22
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-08-07
F · Potential for more than minimal harm
2025-05-22
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-08-07
F · Potential for more than minimal harm
2025-05-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-07
F · Potential for more than minimal harm
2025-05-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-08-07
F · Potential for more than minimal harm
2025-05-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-08-07
F · Potential for more than minimal harm
2025-05-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-08-07
L · Immediate jeopardy
2023-09-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-20
F · Potential for more than minimal harm
2023-09-20
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2023-10-20
F · Potential for more than minimal harm
2023-09-20
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-10-20
F · Potential for more than minimal harm
2023-09-20
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2023-10-20
F · Potential for more than minimal harm
2023-09-20
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-10-20
F · Potential for more than minimal harm
2023-09-20
K221 · Egress Deficiencies
Fire Safety
Provide rooms that can be unlocked from inside without a key.
Corrected 2023-10-20
F · Potential for more than minimal harm
2023-09-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-10-20
F · Potential for more than minimal harm
2023-09-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-20
F · Potential for more than minimal harm
2023-09-20
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-10-20
F · Potential for more than minimal harm
2023-09-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-20
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-10-20
F · Potential for more than minimal harm
2022-01-27
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2022-03-09
F · Potential for more than minimal harm
2022-01-27
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 2022-03-09
F · Potential for more than minimal harm
2022-01-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-03-09
F · Potential for more than minimal harm
2022-01-27
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-03-09
F · Potential for more than minimal harm
2022-01-27
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-03-09
F · Potential for more than minimal harm
2022-01-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-03-09
F · Potential for more than minimal harm
2022-01-27
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-03-09
F · Potential for more than minimal harm
2022-01-27
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 2022-03-09
F · Potential for more than minimal harm
2022-01-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-03-09
E · Potential for more than minimal harm
2022-01-27
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 2022-03-09
E · Potential for more than minimal harm
2022-01-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-03-09
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-22
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-06-19
E · Potential for more than minimal harm
2025-05-22
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-06-19
E · Potential for more than minimal harm
2025-05-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-19
E · Potential for more than minimal harm
2025-05-22
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-06-19
D · Potential for more than minimal harm
2025-05-22
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-06-19
D · Potential for more than minimal harm
2025-05-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-19
D · Potential for more than minimal harm
2025-05-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-19
D · Potential for more than minimal harm
2025-05-22
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 2025-06-19
D · Potential for more than minimal harm
2025-05-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-19
D · Potential for more than minimal harm
2025-05-22
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-06-19
D · Potential for more than minimal harm
2023-11-06
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 2023-11-15
F · Potential for more than minimal harm
2023-09-20
F575 · Resident Rights Deficiencies
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2023-10-27
F · Potential for more than minimal harm
2023-09-20
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-10-27
F · Potential for more than minimal harm
2023-09-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-09-20
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 2023-10-27
E · Potential for more than minimal harm
2023-09-20
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 2023-10-27
D · Potential for more than minimal harm
2023-09-20
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 2023-10-27
D · Potential for more than minimal harm
2023-09-20
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-20
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-20
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 2023-10-27
D · Potential for more than minimal harm
2023-09-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-20
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 2023-10-27
D · Potential for more than minimal harm
2023-09-20
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 2023-10-27
D · Potential for more than minimal harm
2023-09-20
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-10-27
C · Minimal harm
2023-09-20
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-03-20
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 2023-04-14
D · Potential for more than minimal harm
2023-03-20
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 2023-04-14
F · Potential for more than minimal harm
2022-01-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-02-22
E · Potential for more than minimal harm
2022-01-27
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2022-02-22
E · Potential for more than minimal harm
2022-01-27
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2022-02-22
E · Potential for more than minimal harm
2022-01-27
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-02-22
E · Potential for more than minimal harm
2022-01-27
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 2022-02-22
E · Potential for more than minimal harm
2022-01-27
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 2022-02-22
D · Potential for more than minimal harm
2022-01-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-02-22
D · Potential for more than minimal harm
2022-01-27
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2022-02-22
D · Potential for more than minimal harm
2022-01-27
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-02-22
D · Potential for more than minimal harm
2022-01-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-02-22
D · Potential for more than minimal harm
2022-01-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-02-22
D · Potential for more than minimal harm
2022-01-27
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 2022-02-22
D · Potential for more than minimal harm
2022-01-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-02-22
D · Potential for more than minimal harm
2022-01-27
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 2022-02-22
D · Potential for more than minimal harm
2022-01-27
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 2022-02-22
D · Potential for more than minimal harm
2022-01-27
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-02-22
D · Potential for more than minimal harm
2022-01-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-02-22
Penalties and ownership
What sits behind the stars
$13,056
2023-10-03
Fine
Fine · fine $13,056
Fine
Ownership
Akkulugari, Shyam
Operational/Managerial Control · Individual
Hartman, Ashley
Operational/Managerial Control · Individual
Margulies, Zisha
Operational/Managerial Control · Individual
Mrc SNF Management LLC
Operational/Managerial Control · Organization
Reynolds, Stephanie
Operational/Managerial Control · Individual
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