Cycle 1
Health 2024-10-31 · Fire 2024-10-31
14 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
22 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Herington, KS
Legacy At Herington
1-star overall rating with 1-star inspections with $29,273 in total fines with 14 recent health deficiencies with 22 fire-safety deficiencies in the latest cycle
2 E Ash Street, Herington, KS
(785) 258-2283
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
45
Certified beds
Average residents
28
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Campbell Street Services
Operator or chain grouping
Approved since
2006-05-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.77
Registered nurse staffing
LPN hours / resident day
0.53
Licensed practical nurse staffing
Aide hours / resident day
2.83
Nurse aide staffing
Weekend hours
3.50
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
63%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.6 |
1.8
1.2 pts better
|
1.9
1.3 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.2
1 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.4% |
91.8%
1.4 pts worse
|
93.4%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.5%
4.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
4.4%
2.7 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
5.6%
4.7 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.6% |
5.0%
0.4 pts better
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who received an antipsychotic medication | 25.9% |
19.8%
6.1 pts worse
|
16.7%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.0% |
18.4%
7.6 pts worse
|
16.3%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.2% |
18.8%
2.4 pts worse
|
14.9%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
1.8%
0.4 pts better
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 3.5% |
3.1%
0.4 pts worse
|
1.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.0% |
23.2%
2.2 pts better
|
19.8%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 8.3% |
4.6%
3.7 pts worse
|
5.1%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.7% |
75.6%
17.1 pts better
|
81.7%
11 pts better
|
Short Stay · 2024Q4-2025Q3 |
| 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 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-22 · Fire 2023-05-22
25 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2021-09-27 · Fire 2021-09-27
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-10
F · Potential for more than minimal harm
2025-03-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-10
F · Potential for more than minimal harm
2024-10-31
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-12-16
F · Potential for more than minimal harm
2024-10-31
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-12-19
F · Potential for more than minimal harm
2024-10-31
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-12-19
F · Potential for more than minimal harm
2024-10-31
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-12-19
F · Potential for more than minimal harm
2024-10-31
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-12-19
F · Potential for more than minimal harm
2024-10-31
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-12-19
F · Potential for more than minimal harm
2024-10-31
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 2024-12-19
F · Potential for more than minimal harm
2024-10-31
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-12-16
F · Potential for more than minimal harm
2024-10-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-19
F · Potential for more than minimal harm
2024-10-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-19
F · Potential for more than minimal harm
2024-10-31
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-16
F · Potential for more than minimal harm
2024-10-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-19
F · Potential for more than minimal harm
2024-10-31
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-19
F · Potential for more than minimal harm
2024-10-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-19
F · Potential for more than minimal harm
2024-10-31
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-12-16
F · Potential for more than minimal harm
2024-10-31
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-12-16
F · Potential for more than minimal harm
2024-10-31
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-12-16
F · Potential for more than minimal harm
2024-10-31
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-19
E · Potential for more than minimal harm
2024-10-31
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-10-31
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-12-16
F · Potential for more than minimal harm
2023-05-22
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-07-17
F · Potential for more than minimal harm
2023-05-22
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-07-17
F · Potential for more than minimal harm
2023-05-22
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-07-17
F · Potential for more than minimal harm
2023-05-22
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 2023-07-17
F · Potential for more than minimal harm
2023-05-22
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-07-17
F · Potential for more than minimal harm
2023-05-22
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 2023-07-17
F · Potential for more than minimal harm
2023-05-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-17
F · Potential for more than minimal harm
2023-05-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-17
F · Potential for more than minimal harm
2023-05-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-17
F · Potential for more than minimal harm
2023-05-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-07-17
F · Potential for more than minimal harm
2023-05-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-17
F · Potential for more than minimal harm
2023-05-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-17
F · Potential for more than minimal harm
2023-05-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-07-17
F · Potential for more than minimal harm
2023-05-22
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 2023-07-17
F · Potential for more than minimal harm
2023-05-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-07-17
E · Potential for more than minimal harm
2023-05-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-07-17
D · Potential for more than minimal harm
2023-05-22
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 2023-07-17
F · Potential for more than minimal harm
2021-09-27
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2021-12-20
F · Potential for more than minimal harm
2021-09-27
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 2021-12-20
F · Potential for more than minimal harm
2021-09-27
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-12-20
F · Potential for more than minimal harm
2021-09-27
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-12-20
F · Potential for more than minimal harm
2021-09-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-12-20
F · Potential for more than minimal harm
2021-09-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-12-20
F · Potential for more than minimal harm
2021-09-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-12-20
F · Potential for more than minimal harm
2021-09-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-12-20
F · Potential for more than minimal harm
2021-09-27
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2021-12-20
E · Potential for more than minimal harm
2021-09-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-12-20
E · Potential for more than minimal harm
2021-09-27
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 2021-12-20
E · Potential for more than minimal harm
2021-09-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-12-20
E · Potential for more than minimal harm
2021-09-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-12-20
E · Potential for more than minimal harm
2021-09-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-12-20
E · Potential for more than minimal harm
2021-09-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-12-20
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-10-31
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 2024-11-17
F · Potential for more than minimal harm
2024-10-31
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-17
F · Potential for more than minimal harm
2024-10-31
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-11-17
D · Potential for more than minimal harm
2024-10-31
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-17
D · Potential for more than minimal harm
2024-10-31
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 2024-11-17
D · Potential for more than minimal harm
2024-10-31
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 2024-11-17
D · Potential for more than minimal harm
2024-10-31
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-11-17
D · Potential for more than minimal harm
2024-10-31
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-11-17
D · Potential for more than minimal harm
2024-10-31
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-11-17
D · Potential for more than minimal harm
2024-10-31
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-11-17
D · Potential for more than minimal harm
2024-10-31
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-11-17
D · Potential for more than minimal harm
2024-10-31
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 2024-11-17
D · Potential for more than minimal harm
2024-10-31
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-11-17
C · Minimal harm
2024-10-31
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-11-17
D · Potential for more than minimal harm
2024-04-03
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-04-03
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-04-03
F564 · Resident Rights Deficiencies
Health
Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.
Corrected 2024-04-18
D · Potential for more than minimal harm
2023-09-20
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 2023-10-09
D · Potential for more than minimal harm
2023-09-20
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 2023-10-09
J · Immediate jeopardy
2023-05-22
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 2023-07-05
J · Immediate jeopardy
2023-05-22
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 2023-04-24
F · Potential for more than minimal harm
2023-05-22
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 2023-07-05
F · Potential for more than minimal harm
2023-05-22
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 2023-07-05
F · Potential for more than minimal harm
2023-05-22
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-07-05
F · Potential for more than minimal harm
2023-05-22
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-07-05
F · Potential for more than minimal harm
2023-05-22
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-07-05
F · Potential for more than minimal harm
2023-05-22
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-07-05
E · Potential for more than minimal harm
2023-05-22
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 2023-07-05
E · Potential for more than minimal harm
2023-05-22
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 2023-07-05
E · Potential for more than minimal harm
2023-05-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-05-22
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 2023-07-05
D · Potential for more than minimal harm
2023-05-22
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 2023-07-05
D · Potential for more than minimal harm
2023-05-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-05-22
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 2023-07-05
D · Potential for more than minimal harm
2023-05-22
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 2023-07-05
D · Potential for more than minimal harm
2023-05-22
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-05-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-05-22
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-05-22
F779 · Administration Deficiencies
Health
Keep signed and dated reports of x-rays and other diagnostic services in the residents record.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-05-22
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-05-22
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-03-01
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-03-31
D · Potential for more than minimal harm
2021-09-27
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2021-10-08
D · Potential for more than minimal harm
2021-09-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-10-08
D · Potential for more than minimal harm
2021-09-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-10-08
Penalties and ownership
What sits behind the stars
$29,273
2023-05-22
Fine
Fine · fine $29,273
Fine
$0
2023-05-22
Payment Denial
Payment Denial · denial start 2023-06-21 · 14 days
14 day denial
Ownership
Ks Portfolio Master SNF Holdco, LLC
5% Or Greater Direct Ownership Interest · Organization
Arbor Springs, Inc.
Operational/Managerial Control · Organization
Bush, Stephanie
W-2 Managing Employee · Individual
Campbell Street Services LLC
Operational/Managerial Control · Organization
Dole, Isaac
Corporate Director · Individual
Dole, Isaac
Corporate Officer · Individual
Ks Portfolio Investor, LLC
5% Or Greater Indirect Ownership Interest · Organization
Ks Portfolio Master Holdco, LLC
5% Or Greater Indirect Ownership Interest · Organization
Ks Portfolio Sponsor, LLC
5% Or Greater Indirect Ownership Interest · Organization
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Other facilities in reach
#1
Enterprise Estates Nursing Center
Enterprise, KS
1-star overall rating with 1-star inspections with $16,556 in total fines with 11 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Chapman Valley Manor
Chapman, KS
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Memorial Hospital Ltcu (Village Manor)
Abilene, KS
3-star overall rating with 3-star inspections with $15,593 in total fines with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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