Cycle 1
Health 2024-10-09 · Fire 2024-10-09
18 health deficiencies
Top issue: Resident Rights (7 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Topeka, KS
Legacy On 10th Avenue
1-star overall rating with 1-star inspections with $103,737 in total fines with 18 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
2015 Se 10th Avenue, Topeka, KS
(785) 233-8918
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
52
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Advena Living Communities
Operator or chain grouping
Approved since
1976-11-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 2 overall / 2 health / 2 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.45
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
1.90
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.03
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.13
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.69
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
3.86
CMS adjusted total nurse staffing hours
Case-mix index
1.07
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,405
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.47
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
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
2.49
Performance 53.49% · Measure score 2.49 · Achievement 2.49 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.49 hours · Performance 3.15 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 6 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 45.65% |
8.2%
37.5 pts better
|
Numerator 21 · Denominator 46 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.8
0.2 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.0 · Expected 1.9 · Used in QM five-star |
| 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 · Adjusted 1.2 · Observed 1.3 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
91.8%
7.7 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.1% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.1% |
95.5%
2.6 pts better
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
4.4%
3 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.5% |
5.6%
4.1 pts better
|
11.4%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% |
| Percentage of long-stay residents who lose too much weight | 7.2% |
5.0%
2.2 pts worse
|
5.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 6.5% · Q3 9.1% · Q4 7.0% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 42.1% |
23.2%
18.9 pts worse
|
19.6%
22.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.9% · Q2 45.8% · Q3 42.6% · Q4 37.0% · 4Q avg 42.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 35.0% |
19.8%
15.2 pts worse
|
16.7%
18.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.8% · Q3 30.0% · 4Q avg 35.0% · 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 | 12.3% |
18.4%
6.1 pts better
|
16.3%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 21.1% · Q3 4.1% · Q4 20.3% · 4Q avg 12.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.5% |
18.8%
0.7 pts worse
|
14.9%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 16.7% · Q3 17.0% · Q4 26.7% · 4Q avg 19.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.7% |
1.8%
0.9 pts worse
|
1.0%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.7% · Q3 5.1% · Q4 0.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 7.0% |
3.1%
3.9 pts worse
|
1.7%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 2.0% · Q3 6.1% · Q4 4.1% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.7% |
23.2%
9.5 pts better
|
19.8%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 6.1% · Q3 20.8% · Q4 17.9% · 4Q avg 13.7% |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
4.6%
1.2 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.1% · Q3 2.8% · Q4 4.6% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
75.6%
24.4 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-18 · Fire 2023-04-18
17 health deficiencies
Top issue: Resident Rights (5 deficiencies)
22 fire-safety deficiencies
Top issue: Emergency Preparedness (8 deficiencies)
Cycle 3
Health 2021-10-25 · Fire 2021-10-25
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
23 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-09
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-12-12
F · Potential for more than minimal harm
2024-10-09
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-12-12
F · Potential for more than minimal harm
2024-10-09
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 2024-12-12
F · Potential for more than minimal harm
2024-10-09
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-12-12
F · Potential for more than minimal harm
2024-10-09
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 2024-12-12
F · Potential for more than minimal harm
2024-10-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-12
F · Potential for more than minimal harm
2024-10-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-16
F · Potential for more than minimal harm
2024-10-09
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-12-12
F · Potential for more than minimal harm
2024-10-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-16
F · Potential for more than minimal harm
2024-10-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-12
F · Potential for more than minimal harm
2024-10-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-12
F · Potential for more than minimal harm
2024-10-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-12
F · Potential for more than minimal harm
2024-10-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-16
F · Potential for more than minimal harm
2024-10-09
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2024-12-12
F · Potential for more than minimal harm
2024-10-09
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 2024-12-12
F · Potential for more than minimal harm
2024-10-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-12
F · Potential for more than minimal harm
2024-10-09
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-12-12
F · Potential for more than minimal harm
2023-04-18
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2023-06-15
F · Potential for more than minimal harm
2023-04-18
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-06-15
F · Potential for more than minimal harm
2023-04-18
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2023-06-15
F · Potential for more than minimal harm
2023-04-18
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2023-06-15
F · Potential for more than minimal harm
2023-04-18
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-06-15
F · Potential for more than minimal harm
2023-04-18
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-06-15
F · Potential for more than minimal harm
2023-04-18
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-06-15
F · Potential for more than minimal harm
2023-04-18
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-06-15
F · Potential for more than minimal harm
2023-04-18
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-06-15
F · Potential for more than minimal harm
2023-04-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-15
F · Potential for more than minimal harm
2023-04-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-15
F · Potential for more than minimal harm
2023-04-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-15
F · Potential for more than minimal harm
2023-04-18
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-06-15
F · Potential for more than minimal harm
2023-04-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-15
F · Potential for more than minimal harm
2023-04-18
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2023-06-15
E · Potential for more than minimal harm
2023-04-18
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-06-15
E · Potential for more than minimal harm
2023-04-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-06-15
E · Potential for more than minimal harm
2023-04-18
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 2023-06-15
E · Potential for more than minimal harm
2023-04-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-15
E · Potential for more than minimal harm
2023-04-18
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-06-15
E · Potential for more than minimal harm
2023-04-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-06-15
E · Potential for more than minimal harm
2023-04-18
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-06-15
F · Potential for more than minimal harm
2021-10-25
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2021-12-20
F · Potential for more than minimal harm
2021-10-25
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
2021-10-25
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2021-12-20
F · Potential for more than minimal harm
2021-10-25
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2021-12-20
F · Potential for more than minimal harm
2021-10-25
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
2021-10-25
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
2021-10-25
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-12-20
F · Potential for more than minimal harm
2021-10-25
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
F · Potential for more than minimal harm
2021-10-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-12-20
F · Potential for more than minimal harm
2021-10-25
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
2021-10-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-12-20
F · Potential for more than minimal harm
2021-10-25
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
2021-10-25
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-12-20
F · Potential for more than minimal harm
2021-10-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-12-20
F · Potential for more than minimal harm
2021-10-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-12-20
F · Potential for more than minimal harm
2021-10-25
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 2021-12-20
F · Potential for more than minimal harm
2021-10-25
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-12-20
F · Potential for more than minimal harm
2021-10-25
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 2021-12-20
F · Potential for more than minimal harm
2021-10-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-12-20
E · Potential for more than minimal harm
2021-10-25
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2021-12-20
E · Potential for more than minimal harm
2021-10-25
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2021-12-20
E · Potential for more than minimal harm
2021-10-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-12-20
E · Potential for more than minimal harm
2021-10-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-12-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-07
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 2025-07-02
F · Potential for more than minimal harm
2024-10-09
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 2024-11-20
E · Potential for more than minimal harm
2024-10-09
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-10-09
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-10-09
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-10-09
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-10-09
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-10-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-10-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-10-09
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-10-09
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-10-09
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-10-09
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-10-09
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 2024-11-20
D · Potential for more than minimal harm
2024-10-09
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 2024-11-20
D · Potential for more than minimal harm
2024-10-09
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 2024-11-20
C · Minimal harm
2024-10-09
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-11-20
C · Minimal harm
2024-10-09
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-06-18
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 2024-07-19
D · Potential for more than minimal harm
2024-06-18
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 2024-07-19
E · Potential for more than minimal harm
2024-04-23
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 2024-05-31
D · Potential for more than minimal harm
2023-10-25
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 2023-12-06
D · Potential for more than minimal harm
2023-10-25
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-10-02
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 2023-10-27
K · Immediate jeopardy
2023-07-11
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-04
J · Immediate jeopardy
2023-07-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-08-04
D · Potential for more than minimal harm
2023-07-11
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-08-04
J · Immediate jeopardy
2023-04-18
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 2023-06-30
F · Potential for more than minimal harm
2023-04-18
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 2023-05-22
F · Potential for more than minimal harm
2023-04-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-22
E · Potential for more than minimal harm
2023-04-18
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 2023-06-30
E · Potential for more than minimal harm
2023-04-18
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 2023-05-22
E · Potential for more than minimal harm
2023-04-18
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 2023-05-22
E · Potential for more than minimal harm
2023-04-18
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-05-22
D · Potential for more than minimal harm
2023-04-18
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 2023-05-22
D · Potential for more than minimal harm
2023-04-18
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-05-22
D · Potential for more than minimal harm
2023-04-18
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-05-22
D · Potential for more than minimal harm
2023-04-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-05-22
D · Potential for more than minimal harm
2023-04-18
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-05-22
D · Potential for more than minimal harm
2023-04-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-04-18
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-05-22
F · Potential for more than minimal harm
2021-10-25
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 2021-11-25
F · Potential for more than minimal harm
2021-10-25
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2021-11-25
E · Potential for more than minimal harm
2021-10-25
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 2021-11-25
E · Potential for more than minimal harm
2021-10-25
F924 · Environmental Deficiencies
Health
Put firmly secured handrails on each side of hallways.
Corrected 2021-11-25
Penalties and ownership
What sits behind the stars
$103,737
2023-04-18
Fine
Fine · fine $103,737
Fine
$0
2023-04-18
Payment Denial
Payment Denial · denial start 2023-05-17 · 79 days
79 day denial
Ownership
New Paradigm Solutions Inc
Operational/Managerial Control · Organization
Novotny, Michelle
Operational/Managerial Control · Individual
Novotny, William
Operational/Managerial Control · Individual
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