Cycle 1
Health 2025-02-13 · Fire 2025-02-13
17 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
21 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Wichita, KS
Legacy At College Hill
1-star overall rating with 1-star inspections with Special Focus status with $96,031 in total fines with 17 recent health deficiencies with 21 fire-safety deficiencies in the latest cycle
5005 E 21st Street North, Wichita, KS
(316) 685-9291
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
75
Certified beds
Average residents
69
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Campbell Street Services
Operator or chain grouping
Approved since
1969-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
16 facilities
Chain averages 2 overall / 2 health / 3 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
0.31
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.73
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.86
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.12
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.56
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.21
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
0.34
CMS adjusted RN staffing hours
Adjusted total hours
4.30
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
48%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,700
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.21
Composite VBP score used to determine payment impact.
Payment multiplier
1.0019
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
5.23
Baseline 59.65% · Performance 42.31% · Measure score 5.23 · Achievement 5.23 · Improvement 4.48
Adjusted total nurse staffing
4.41
Baseline 3.63 hours · Performance 4.33 hours · Measure score 4.41 · Achievement 4.41 · Improvement 2.76
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.04% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 36 · Observed rate 8.33% · Lower 95% interval 6.27% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 32 · Denominator 32 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 32 |
| Discharge self-care score | 30.43% |
53.69%
23.3 pts worse
|
Numerator 7 · Denominator 23 |
| Discharge mobility score | 26.09% |
50.94%
24.8 pts worse
|
Numerator 6 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 15.63% |
2.29%
13.3 pts worse
|
Numerator 5 · Denominator 32 · Adjusted rate 11.03% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 17.17% |
8.2%
9 pts better
|
Numerator 17 · Denominator 99 |
| Staff flu vaccination coverage | 28.87% |
42%
13.1 pts worse
|
Numerator 28 · Denominator 97 |
| Discharge function score | 34.78% |
56.45%
21.7 pts worse
|
Numerator 8 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · 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 | 3.1 |
1.8
1.3 pts worse
|
1.9
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 3.3 · Expected 2.0 · 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 2.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.0% |
91.8%
0.8 pts worse
|
93.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 81.8% · Q2 89.7% · Q3 95.5% · Q4 97.0% · 4Q avg 91.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
95.5%
3.1 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.1% |
4.4%
0.3 pts better
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.9% · Q3 3.0% · Q4 7.6% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.0% |
5.6%
1.6 pts better
|
11.4%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 1.7% · Q3 1.8% · Q4 1.9% · 4Q avg 4.0% |
| Percentage of long-stay residents who lose too much weight | 10.4% |
5.0%
5.4 pts worse
|
5.4%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 13.8% · Q3 6.6% · Q4 13.3% · 4Q avg 10.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.4% |
23.2%
2.8 pts better
|
19.6%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 21.0% · Q3 19.0% · Q4 21.3% · 4Q avg 20.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.1% |
19.8%
2.3 pts worse
|
16.7%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 19.4% · Q3 21.1% · Q4 20.5% · 4Q avg 22.1% · 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 | 7.8% |
18.4%
10.6 pts better
|
16.3%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 0.0% · Q3 9.5% · Q4 6.5% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.6% |
18.8%
3.2 pts better
|
14.9%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 19.7% · Q3 13.3% · Q4 10.2% · 4Q avg 15.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
1.8%
0.3 pts better
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
3.1%
1.5 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.7% · Q3 1.5% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.7% |
23.2%
12.5 pts better
|
19.8%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.6% · Q2 8.2% · Q3 12.2% · Q4 6.5% · 4Q avg 10.7% |
| Percentage of long-stay residents with pressure ulcers | 6.7% |
4.6%
2.1 pts worse
|
5.1%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 7.1% · Q3 6.2% · Q4 7.3% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.6% |
75.6%
6 pts better
|
81.7%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 75.0% · Q3 80.0% · 4Q avg 81.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.4% |
11.7%
0.7 pts worse
|
12.0%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.4% · Observed 15.8% · Expected 14.2% · 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 rehospitalized after a nursing home admission | 10.4% |
23.0%
12.6 pts better
|
23.9%
13.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.4% · Observed 13.2% · Expected 30.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-02 · Fire 2023-05-02
31 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
20 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2021-10-05 · Fire 2021-10-05
23 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
22 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
L · Immediate jeopardy
2025-02-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-08
F · Potential for more than minimal harm
2025-02-13
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-04-07
F · Potential for more than minimal harm
2025-02-13
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-04-07
F · Potential for more than minimal harm
2025-02-13
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-04-08
F · Potential for more than minimal harm
2025-02-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-04-07
F · Potential for more than minimal harm
2025-02-13
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 2025-04-08
F · Potential for more than minimal harm
2025-02-13
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 2025-04-07
F · Potential for more than minimal harm
2025-02-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-12
F · Potential for more than minimal harm
2025-02-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-07
F · Potential for more than minimal harm
2025-02-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-07
F · Potential for more than minimal harm
2025-02-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-08
F · Potential for more than minimal harm
2025-02-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-03-12
F · Potential for more than minimal harm
2025-02-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-07
F · Potential for more than minimal harm
2025-02-13
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 2025-04-07
F · Potential for more than minimal harm
2025-02-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-03-12
F · Potential for more than minimal harm
2025-02-13
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 2025-04-07
F · Potential for more than minimal harm
2025-02-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-12
F · Potential for more than minimal harm
2025-02-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-07
F · Potential for more than minimal harm
2025-02-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-04-07
E · Potential for more than minimal harm
2025-02-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-07
E · Potential for more than minimal harm
2025-02-13
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2025-04-08
F · Potential for more than minimal harm
2023-05-02
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-07-26
F · Potential for more than minimal harm
2023-05-02
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2023-07-26
F · Potential for more than minimal harm
2023-05-02
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2023-07-26
F · Potential for more than minimal harm
2023-05-02
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-07-26
F · Potential for more than minimal harm
2023-05-02
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-07-26
F · Potential for more than minimal harm
2023-05-02
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 2023-07-26
F · Potential for more than minimal harm
2023-05-02
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 2023-07-26
F · Potential for more than minimal harm
2023-05-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-26
F · Potential for more than minimal harm
2023-05-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-26
F · Potential for more than minimal harm
2023-05-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-26
F · Potential for more than minimal harm
2023-05-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-07-26
F · Potential for more than minimal harm
2023-05-02
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2023-07-26
F · Potential for more than minimal harm
2023-05-02
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-07-26
F · Potential for more than minimal harm
2023-05-02
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-07-26
F · Potential for more than minimal harm
2023-05-02
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-07-26
F · Potential for more than minimal harm
2023-05-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-26
F · Potential for more than minimal harm
2023-05-02
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-07-26
F · Potential for more than minimal harm
2023-05-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-26
F · Potential for more than minimal harm
2023-05-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-07-26
E · Potential for more than minimal harm
2023-05-02
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 2023-07-26
F · Potential for more than minimal harm
2021-10-05
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2021-12-15
F · Potential for more than minimal harm
2021-10-05
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2021-12-15
F · Potential for more than minimal harm
2021-10-05
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2021-12-15
F · Potential for more than minimal harm
2021-10-05
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2021-12-15
F · Potential for more than minimal harm
2021-10-05
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2021-12-15
F · Potential for more than minimal harm
2021-10-05
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 2021-12-15
F · Potential for more than minimal harm
2021-10-05
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-12-15
F · Potential for more than minimal harm
2021-10-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-12-15
F · Potential for more than minimal harm
2021-10-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-12-15
F · Potential for more than minimal harm
2021-10-05
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2021-12-15
F · Potential for more than minimal harm
2021-10-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-12-15
F · Potential for more than minimal harm
2021-10-05
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2021-12-15
F · Potential for more than minimal harm
2021-10-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-12-15
F · Potential for more than minimal harm
2021-10-05
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2021-12-15
F · Potential for more than minimal harm
2021-10-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-12-15
F · Potential for more than minimal harm
2021-10-05
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2021-12-15
F · Potential for more than minimal harm
2021-10-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-12-15
F · Potential for more than minimal harm
2021-10-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-12-15
F · Potential for more than minimal harm
2021-10-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-12-15
F · Potential for more than minimal harm
2021-10-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-12-15
E · Potential for more than minimal harm
2021-10-05
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 2021-12-15
D · Potential for more than minimal harm
2021-10-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-12-15
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-21
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-05-21
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 2025-06-20
D · Potential for more than minimal harm
2025-05-21
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 2025-06-20
F · Potential for more than minimal harm
2025-02-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-07
F · Potential for more than minimal harm
2025-02-13
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 2025-03-07
E · Potential for more than minimal harm
2025-02-13
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 2025-03-07
E · Potential for more than minimal harm
2025-02-13
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-02-13
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 2025-03-07
D · Potential for more than minimal harm
2025-02-13
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 2025-03-07
D · Potential for more than minimal harm
2025-02-13
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 2025-03-07
D · Potential for more than minimal harm
2025-02-13
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-02-13
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-02-13
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 2025-03-07
D · Potential for more than minimal harm
2025-02-13
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-02-13
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 2025-03-07
D · Potential for more than minimal harm
2025-02-13
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-02-13
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-03-07
G · Actual harm
2024-07-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-30
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 2024-08-23
D · Potential for more than minimal harm
2024-07-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-30
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 2024-08-23
D · Potential for more than minimal harm
2024-07-30
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-23
L · Immediate jeopardy
2023-05-02
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 2023-06-15
L · Immediate jeopardy
2023-05-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-15
K · Immediate jeopardy
2023-05-02
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 2023-06-15
G · Actual harm
2023-05-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-15
F · Potential for more than minimal harm
2023-05-02
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-06-15
F · Potential for more than minimal harm
2023-05-02
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 2023-06-15
F · Potential for more than minimal harm
2023-05-02
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-06-15
F · Potential for more than minimal harm
2023-05-02
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-15
F · Potential for more than minimal harm
2023-05-02
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-06-15
F · Potential for more than minimal harm
2023-05-02
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-06-15
F · Potential for more than minimal harm
2023-05-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-15
F · Potential for more than minimal harm
2023-05-02
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-06-15
E · Potential for more than minimal harm
2023-05-02
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-06-15
E · Potential for more than minimal harm
2023-05-02
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 2023-06-15
E · Potential for more than minimal harm
2023-05-02
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 2023-06-15
E · Potential for more than minimal harm
2023-05-02
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 2023-06-15
D · Potential for more than minimal harm
2023-05-02
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-05-02
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-05-02
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-05-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-05-02
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 2023-06-15
D · Potential for more than minimal harm
2023-05-02
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 2023-06-15
D · Potential for more than minimal harm
2023-05-02
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-05-02
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-05-02
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-06-15
J · Immediate jeopardy
2023-04-10
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 2023-04-05
G · Actual harm
2021-10-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-11-08
G · Actual harm
2021-10-05
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-11-08
F · Potential for more than minimal harm
2021-10-05
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 2021-11-08
F · Potential for more than minimal harm
2021-10-05
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2021-11-08
F · Potential for more than minimal harm
2021-10-05
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 2021-11-08
F · Potential for more than minimal harm
2021-10-05
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2021-11-08
F · Potential for more than minimal harm
2021-10-05
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2021-11-08
F · Potential for more than minimal harm
2021-10-05
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2021-11-08
D · Potential for more than minimal harm
2021-10-05
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 2021-11-08
D · Potential for more than minimal harm
2021-10-05
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2021-11-08
D · Potential for more than minimal harm
2021-10-05
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 2021-11-08
D · Potential for more than minimal harm
2021-10-05
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 2021-11-08
D · Potential for more than minimal harm
2021-10-05
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 2021-11-08
D · Potential for more than minimal harm
2021-10-05
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-11-08
D · Potential for more than minimal harm
2021-10-05
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 2021-11-08
D · Potential for more than minimal harm
2021-10-05
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-11-08
D · Potential for more than minimal harm
2021-10-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-11-08
D · Potential for more than minimal harm
2021-10-05
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 2021-11-08
D · Potential for more than minimal harm
2021-10-05
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-11-08
D · Potential for more than minimal harm
2021-10-05
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 2021-11-08
D · Potential for more than minimal harm
2021-10-05
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-11-08
D · Potential for more than minimal harm
2021-10-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-11-08
Penalties and ownership
What sits behind the stars
$8,281
2025-03-12
Fine
Fine · fine $8,281
Fine
$0
2025-03-12
Payment Denial
Payment Denial · denial start 2025-03-29 · 10 days
10 day denial
$34,775
2024-07-30
Fine
Fine · fine $34,775
Fine
$43,660
2023-05-02
Fine
Fine · fine $43,660
Fine
$0
2023-05-02
Payment Denial
Payment Denial · denial start 2023-05-30 · 16 days
16 day denial
$9,315
2023-04-10
Fine
Fine · fine $9,315
Fine
Ownership
Ks Portfolio Master SNF Holdco, LLC
5% Or Greater Direct Ownership Interest · Organization
Adams, John
5% Or Greater Indirect Ownership Interest · Individual
Bryant, Rodney
Operational/Managerial Control · Individual
Campbell Street Services LLC
Operational/Managerial Control · Organization
College Hills Realco, LLC
5% Or Greater Mortgage Interest · Organization
Dole, Isaac
Corporate Officer · Individual
Fishfeld, Jordan
5% Or Greater Indirect Ownership Interest · Individual
Fox, Amy
Operational/Managerial Control · Individual
Griffin, Steven
Operational/Managerial Control · Individual
Ks Portfolio Investor, LLC
5% Or Greater Indirect Ownership Interest · Organization
Ks Portfolio Manager, LLC
Operational/Managerial Control · Organization
Ks Portfolio Master Holdco, LLC
5% Or Greater Indirect Ownership Interest · Organization
Ks Portfolio Sponsor, LLC
5% Or Greater Indirect Ownership Interest · Organization
Mendelovitz, Isidore
5% Or Greater Indirect Ownership Interest · Individual
Nkero Investments Ltd Llp
5% Or Greater Indirect Ownership Interest · Organization
Tolia, Kirit
5% Or Greater Indirect Ownership Interest · Individual
Tolia, Sanjay
5% Or Greater Indirect Ownership Interest · Individual
Tolia, Vinay
5% Or Greater Indirect Ownership Interest · Individual
Nearby options
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#2
Larksfield Place
Wichita, KS
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Life Care Center Of Wichita
Wichita, KS
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
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