Cycle 1
Health 2024-08-05 · Fire 2024-08-05
20 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
21 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Wichita, KS
Meridian Rehabilitation And Health Care Center
2-star overall rating with 1-star inspections with abuse icon flag with $84,501 in total fines with 20 recent health deficiencies with 21 fire-safety deficiencies in the latest cycle
1555 N Meridian Street, Wichita, KS
(316) 942-8471
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
106
Certified beds
Average residents
99
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Tutera Senior Living & Health Care
Operator or chain grouping
Approved since
1994-02-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
25 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.34
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
1.96
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.22
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.86
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
3.59
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,729
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.54
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
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
0
Baseline 59.80% · Performance 61.77% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.11
Baseline 4.02 hours · Performance 3.96 hours · Measure score 3.11 · Achievement 3.11 · 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 22 · 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 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 19 · 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 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 8.22% |
8.2%
About the same
|
Numerator 6 · Denominator 73 |
| Staff flu vaccination coverage | 14.04% |
42%
28 pts worse
|
Numerator 25 · Denominator 178 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
91.8%
6.2 pts better
|
93.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.3% · Q2 98.8% · Q3 97.8% · Q4 100.0% · 4Q avg 98.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.8% |
95.5%
1.7 pts worse
|
95.5%
1.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
4.4%
1.6 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 4.3% · Q4 4.3% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 14.6% |
5.6%
9 pts worse
|
11.4%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 18.7% · Q3 12.5% · Q4 10.2% · 4Q avg 14.6% |
| Percentage of long-stay residents who lose too much weight | 6.0% |
5.0%
1 pts worse
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 8.8% · Q3 1.2% · Q4 8.0% · 4Q avg 6.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.8% |
23.2%
8.4 pts better
|
19.6%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 13.0% · Q3 16.3% · Q4 13.8% · 4Q avg 14.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.9% |
19.8%
2.1 pts worse
|
16.7%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 23.1% · Q3 21.6% · Q4 24.5% · 4Q avg 21.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.5% |
18.4%
6.9 pts better
|
16.3%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 16.8% · Q3 7.6% · Q4 9.9% · 4Q avg 11.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.7% |
18.8%
8.1 pts better
|
14.9%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 14.7% · Q3 11.9% · Q4 8.1% · 4Q avg 10.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
1.8%
1.6 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.8% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
3.1%
3.1 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.5% |
23.2%
9.7 pts better
|
19.8%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 11.4% · Q3 12.1% · Q4 13.4% · 4Q avg 13.5% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
4.6%
0.7 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 4.6% · Q3 2.8% · Q4 3.9% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.6% |
75.6%
8 pts better
|
81.7%
1.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 63.8% · Q2 82.5% · Q3 94.2% · Q4 94.9% · 4Q avg 83.6% |
| 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 · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.3% |
73.5%
8.8 pts better
|
79.7%
2.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.3% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-13 · Fire 2022-12-13
26 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
21 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Cycle 3
Health 2021-04-22 · Fire 2021-04-22
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-05
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-05
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-05
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-05
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-05
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 2024-09-30
F · Potential for more than minimal harm
2024-08-05
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-05
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 2024-09-30
F · Potential for more than minimal harm
2024-08-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-05
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-05
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-05
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 2024-09-30
F · Potential for more than minimal harm
2024-08-05
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 2024-09-30
F · Potential for more than minimal harm
2024-08-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-09-30
F · Potential for more than minimal harm
2022-12-13
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2023-03-07
F · Potential for more than minimal harm
2022-12-13
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2023-03-07
F · Potential for more than minimal harm
2022-12-13
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2023-03-07
F · Potential for more than minimal harm
2022-12-13
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-03-07
F · Potential for more than minimal harm
2022-12-13
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-03-07
F · Potential for more than minimal harm
2022-12-13
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-03-07
F · Potential for more than minimal harm
2022-12-13
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-03-07
F · Potential for more than minimal harm
2022-12-13
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-03-07
F · Potential for more than minimal harm
2022-12-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-07
F · Potential for more than minimal harm
2022-12-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-07
F · Potential for more than minimal harm
2022-12-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-07
F · Potential for more than minimal harm
2022-12-13
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-03-07
F · Potential for more than minimal harm
2022-12-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-07
F · Potential for more than minimal harm
2022-12-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-07
F · Potential for more than minimal harm
2022-12-13
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 2023-03-07
F · Potential for more than minimal harm
2022-12-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-07
F · Potential for more than minimal harm
2022-12-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-07
E · Potential for more than minimal harm
2022-12-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-03-07
E · Potential for more than minimal harm
2022-12-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-03-07
D · Potential for more than minimal harm
2022-12-13
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-03-07
D · Potential for more than minimal harm
2022-12-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-03-07
F · Potential for more than minimal harm
2021-04-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-07-16
F · Potential for more than minimal harm
2021-04-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-07-16
F · Potential for more than minimal harm
2021-04-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-07-16
F · Potential for more than minimal harm
2021-04-22
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 2021-07-16
F · Potential for more than minimal harm
2021-04-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-06-23
F · Potential for more than minimal harm
2021-04-22
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2021-07-16
E · Potential for more than minimal harm
2021-04-22
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 2021-07-16
E · Potential for more than minimal harm
2021-04-22
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-07-16
E · Potential for more than minimal harm
2021-04-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-07-16
E · Potential for more than minimal harm
2021-04-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-07-16
Inspection history
Recent health citations
J · Immediate jeopardy
2024-08-05
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 2024-07-23
J · Immediate jeopardy
2024-08-05
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 2024-07-02
J · Immediate jeopardy
2024-08-05
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2024-07-23
F · Potential for more than minimal harm
2024-08-05
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-09-03
F · Potential for more than minimal harm
2024-08-05
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-09-03
F · Potential for more than minimal harm
2024-08-05
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2024-09-03
E · Potential for more than minimal harm
2024-08-05
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-09-03
E · Potential for more than minimal harm
2024-08-05
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 2024-09-03
E · Potential for more than minimal harm
2024-08-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-03
E · Potential for more than minimal harm
2024-08-05
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 2024-09-03
E · Potential for more than minimal harm
2024-08-05
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 2024-09-03
E · Potential for more than minimal harm
2024-08-05
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-09-03
E · Potential for more than minimal harm
2024-08-05
F923 · Environmental Deficiencies
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2024-09-03
D · Potential for more than minimal harm
2024-08-05
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-09-03
D · Potential for more than minimal harm
2024-08-05
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-09-03
D · Potential for more than minimal harm
2024-08-05
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-09-03
D · Potential for more than minimal harm
2024-08-05
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-09-03
D · Potential for more than minimal harm
2024-08-05
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-09-03
D · Potential for more than minimal harm
2024-08-05
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 2024-09-03
D · Potential for more than minimal harm
2024-08-05
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-09-03
J · Immediate jeopardy
2023-08-07
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 2023-07-27
J · Immediate jeopardy
2023-06-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-05-31
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-06-01
D · Potential for more than minimal harm
2023-05-31
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-06-01
G · Actual harm
2022-12-13
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 2023-02-22
F · Potential for more than minimal harm
2022-12-13
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 2023-02-22
F · Potential for more than minimal harm
2022-12-13
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 2023-02-22
F · Potential for more than minimal harm
2022-12-13
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-02-22
F · Potential for more than minimal harm
2022-12-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-22
E · Potential for more than minimal harm
2022-12-13
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-02-22
E · Potential for more than minimal harm
2022-12-13
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 2023-02-22
E · Potential for more than minimal harm
2022-12-13
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 2023-02-22
E · Potential for more than minimal harm
2022-12-13
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-02-22
D · Potential for more than minimal harm
2022-12-13
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 2023-02-22
D · Potential for more than minimal harm
2022-12-13
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 2023-02-22
D · Potential for more than minimal harm
2022-12-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-03-20
D · Potential for more than minimal harm
2022-12-13
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 2023-02-22
D · Potential for more than minimal harm
2022-12-13
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-02-22
D · Potential for more than minimal harm
2022-12-13
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 2023-02-22
D · Potential for more than minimal harm
2022-12-13
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 2023-02-22
D · Potential for more than minimal harm
2022-12-13
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 2023-02-22
D · Potential for more than minimal harm
2022-12-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-22
D · Potential for more than minimal harm
2022-12-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-02-22
D · Potential for more than minimal harm
2022-12-13
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-03-20
D · Potential for more than minimal harm
2022-12-13
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 2023-02-22
D · Potential for more than minimal harm
2022-12-13
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-02-22
D · Potential for more than minimal harm
2022-12-13
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 2023-02-22
D · Potential for more than minimal harm
2022-12-13
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-03-20
D · Potential for more than minimal harm
2022-12-13
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2023-02-22
D · Potential for more than minimal harm
2022-12-13
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 2023-03-20
E · Potential for more than minimal harm
2021-04-22
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2021-05-14
D · Potential for more than minimal harm
2021-04-22
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2021-05-14
D · Potential for more than minimal harm
2021-04-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-05-14
D · Potential for more than minimal harm
2021-04-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-05-14
D · Potential for more than minimal harm
2021-04-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-05-14
D · Potential for more than minimal harm
2021-04-22
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 2021-05-14
D · Potential for more than minimal harm
2021-04-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-05-14
D · Potential for more than minimal harm
2021-04-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-05-14
Penalties and ownership
What sits behind the stars
$13,627
2024-08-05
Fine
Fine · fine $13,627
Fine
$16,055
2024-08-05
Fine
Fine · fine $16,055
Fine
$16,801
2024-08-05
Fine
Fine · fine $16,801
Fine
$15,593
2023-08-07
Fine
Fine · fine $15,593
Fine
$22,425
2023-05-31
Fine
Fine · fine $22,425
Fine
Ownership
Tutera, Joseph
5% Or Greater Direct Ownership Interest · Individual
Tutera Investments, LLC
5% Or Greater Direct Ownership Interest · Organization
Brooks, Kiley
Operational/Managerial Control · Individual
Brooks, Kiley
Corporate Officer · Individual
Gannon, Jeff
Operational/Managerial Control · Individual
Gannon, Jeff
Corporate Officer · Individual
Jct Family Limited Partnership
5% Or Greater Direct Ownership Interest · Organization
Jct Family Limited Partnership
Limited Partnership Interest · Organization
Tutera, Dominic
Limited Partnership Interest · Individual
Tutera, Hannah
Limited Partnership Interest · Individual
Tutera, Joseph
Limited Partnership Interest · Individual
Tutera, Joseph
Operational/Managerial Control · Individual
Tutera, Laura
Limited Partnership Interest · Individual
Walnut Creek Management Company LLC
Operational/Managerial Control · Organization
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