Cycle 1
Health 2025-12-03 · Fire 2025-12-03
23 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Lawrence, KS
Pioneer Ridge Retirement Community
1-star overall rating with 1-star inspections with $14,901 in total fines with 23 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
4851 Harvard Road, Lawrence, KS
(785) 749-2000
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
76
Certified beds
Average residents
61
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Midwest Health
Operator or chain grouping
Approved since
2001-07-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 3 overall / 3 health / 4 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
0.71
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
2.66
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.04
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.39
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.58
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.80
CMS adjusted RN staffing hours
Adjusted total hours
4.56
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,187
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.20
Composite VBP score used to determine payment impact.
Payment multiplier
0.9826
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.69% · Performance 21.76% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.46
Baseline 5.97% · Performance 7.10% · Measure score 2.46 · Achievement 2.46 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
3.89
Baseline 3.43 hours · Performance 4.19 hours · Measure score 3.89 · Achievement 3.89 · Improvement 2.71
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.09% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 230 · Observed rate 8.7% · Lower 95% interval 8.02% |
| Discharge to community | 63.83% |
50.57%
13.3 pts better
|
Better than the National Rate · Eligible stays 207 · Observed rate 66.18% · Lower 95% interval 58.22% |
| Medicare spending per beneficiary | 0.73 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 99.3% |
95.27%
4 pts better
|
Numerator 141 · Denominator 142 |
| Falls with major injury | 0.7% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 142 |
| Discharge self-care score | 49.18% |
53.69%
4.5 pts worse
|
Numerator 60 · Denominator 122 |
| Discharge mobility score | 25.41% |
50.94%
25.5 pts worse
|
Numerator 31 · Denominator 122 |
| Pressure ulcers or injuries, new or worsened | 1.41% |
2.29%
0.9 pts better
|
Numerator 2 · Denominator 142 · Adjusted rate 1.77% |
| Healthcare-associated infections requiring hospitalization | 7.1% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 131 · Observed rate 5.34% · Lower 95% interval 4.57% |
| Staff COVID-19 vaccination coverage | 2.15% |
8.2%
6 pts worse
|
Numerator 2 · Denominator 93 |
| Staff flu vaccination coverage | 47.06% |
42%
5.1 pts better
|
Numerator 48 · Denominator 102 |
| Discharge function score | 56.56% |
56.45%
0.1 pts better
|
Numerator 69 · Denominator 122 |
| Transfer of health information to provider | 96.25% |
95.95%
0.3 pts better
|
Numerator 77 · Denominator 80 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 38 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | 36.23% |
25.2%
11 pts better
|
Numerator 25 · Denominator 69 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.1 |
1.8
1.3 pts worse
|
1.9
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 2.8 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.2
0.7 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.2 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.3% |
91.8%
4.5 pts worse
|
93.4%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 86.8% · Q2 100.0% · Q3 87.2% · Q4 76.7% · 4Q avg 87.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 75.6% |
95.5%
19.9 pts worse
|
95.5%
19.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 75.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.7% |
4.4%
1.3 pts worse
|
3.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 5.4% · Q3 2.6% · Q4 7.0% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.3% |
5.6%
3.3 pts better
|
11.4%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 5.4% · Q4 0.0% · 4Q avg 2.3% |
| Percentage of long-stay residents who lose too much weight | 3.2% |
5.0%
1.8 pts better
|
5.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 3.4% · Q3 0.0% · Q4 2.9% · 4Q avg 3.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.4% |
23.2%
9.8 pts better
|
19.6%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 9.7% · Q3 15.6% · Q4 17.1% · 4Q avg 13.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.2% |
19.8%
9.6 pts better
|
16.7%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 17.4% · Q3 6.9% · Q4 9.7% · 4Q avg 10.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.3% |
18.4%
5.1 pts better
|
16.3%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.0% |
18.8%
6.8 pts better
|
14.9%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 10.0% · Q3 22.6% · Q4 11.4% · 4Q avg 12.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
1.8%
1.2 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.3% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.5% |
3.1%
1.4 pts worse
|
1.7%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 2.9% · Q3 5.3% · Q4 0.0% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.9% |
23.2%
5.7 pts worse
|
19.8%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.0% · Q2 22.8% · Q3 24.1% · Q4 30.9% · 4Q avg 28.9% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
4.6%
1.3 pts worse
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 7.5% · Q3 8.0% · Q4 4.6% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 61.7% |
75.6%
13.9 pts worse
|
81.7%
20 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 85.4% · Q2 78.8% · Q3 55.3% · Q4 39.4% · 4Q avg 61.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.6% |
11.7%
0.1 pts better
|
12.0%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.6% · Observed 10.4% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
2.2%
1.8 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 56.5% |
73.5%
17 pts worse
|
79.7%
23.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 56.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.0% |
23.0%
8 pts worse
|
23.9%
7.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.0% · Observed 24.0% · Expected 18.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-17 · Fire 2024-10-17
15 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-07-19 · Fire 2023-07-19
13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-03
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2026-02-20
F · Potential for more than minimal harm
2025-12-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-02-20
F · Potential for more than minimal harm
2025-12-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-02-20
F · Potential for more than minimal harm
2025-12-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-02-20
E · Potential for more than minimal harm
2025-12-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-20
F · Potential for more than minimal harm
2024-10-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-14
F · Potential for more than minimal harm
2024-10-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-14
F · Potential for more than minimal harm
2024-10-17
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-01-14
F · Potential for more than minimal harm
2024-10-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-14
F · Potential for more than minimal harm
2024-10-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-01-14
F · Potential for more than minimal harm
2024-10-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-14
E · Potential for more than minimal harm
2024-10-17
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-01-14
E · Potential for more than minimal harm
2024-10-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-14
E · Potential for more than minimal harm
2024-10-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-14
E · Potential for more than minimal harm
2024-10-17
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-01-14
E · Potential for more than minimal harm
2024-10-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-14
E · Potential for more than minimal harm
2024-10-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-01-14
F · Potential for more than minimal harm
2023-07-19
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-09-08
F · Potential for more than minimal harm
2023-07-19
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2023-09-08
F · Potential for more than minimal harm
2023-07-19
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 2023-09-08
F · Potential for more than minimal harm
2023-07-19
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-09-08
F · Potential for more than minimal harm
2023-07-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-08
F · Potential for more than minimal harm
2023-07-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-08
F · Potential for more than minimal harm
2023-07-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-08
F · Potential for more than minimal harm
2023-07-19
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-09-08
F · Potential for more than minimal harm
2023-07-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-08
F · Potential for more than minimal harm
2023-07-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-08
F · Potential for more than minimal harm
2023-07-19
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 2023-09-08
F · Potential for more than minimal harm
2023-07-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-12
F · Potential for more than minimal harm
2023-07-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-07-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-08
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-03
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2026-01-14
F · Potential for more than minimal harm
2025-12-03
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 2026-01-14
F · Potential for more than minimal harm
2025-12-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-14
F · Potential for more than minimal harm
2025-12-03
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2026-01-14
F · Potential for more than minimal harm
2025-12-03
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2026-01-14
E · Potential for more than minimal harm
2025-12-03
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 2026-01-14
E · Potential for more than minimal harm
2025-12-03
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2026-01-14
D · Potential for more than minimal harm
2025-12-03
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 2026-01-14
D · Potential for more than minimal harm
2025-12-03
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2026-01-14
D · Potential for more than minimal harm
2025-12-03
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2026-01-14
D · Potential for more than minimal harm
2025-12-03
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-01-14
D · Potential for more than minimal harm
2025-12-03
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 2026-01-14
D · Potential for more than minimal harm
2025-12-03
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 2026-01-14
D · Potential for more than minimal harm
2025-12-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-14
D · Potential for more than minimal harm
2025-12-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-01-14
D · Potential for more than minimal harm
2025-12-03
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 2026-01-14
D · Potential for more than minimal harm
2025-12-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2026-01-14
D · Potential for more than minimal harm
2025-12-03
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2026-01-14
D · Potential for more than minimal harm
2025-12-03
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 2026-01-14
C · Minimal harm
2025-12-03
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2026-01-14
D · Potential for more than minimal harm
2025-08-20
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 2025-09-10
J · Immediate jeopardy
2025-03-19
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 2025-03-11
E · Potential for more than minimal harm
2025-03-19
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 2025-04-11
E · Potential for more than minimal harm
2024-10-17
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 2024-11-22
E · Potential for more than minimal harm
2024-10-17
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-17
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-17
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 2024-11-22
D · Potential for more than minimal harm
2024-10-17
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 2024-11-22
D · Potential for more than minimal harm
2024-10-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-17
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 2024-11-22
D · Potential for more than minimal harm
2024-10-17
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-17
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 2024-11-22
D · Potential for more than minimal harm
2024-10-17
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-17
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 2024-11-22
D · Potential for more than minimal harm
2024-10-17
F775 · Administration Deficiencies
Health
Keep complete, dated laboratory records in the resident's record.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-17
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 2024-11-22
D · Potential for more than minimal harm
2024-10-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-22
E · Potential for more than minimal harm
2023-07-19
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-09-01
E · Potential for more than minimal harm
2023-07-19
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 2023-09-01
E · Potential for more than minimal harm
2023-07-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-07-19
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 2023-09-01
D · Potential for more than minimal harm
2023-07-19
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-07-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-07-19
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 2023-09-01
D · Potential for more than minimal harm
2023-07-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-07-19
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 2023-09-01
D · Potential for more than minimal harm
2023-07-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-07-19
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-07-19
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-09-01
C · Minimal harm
2023-07-19
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 2023-09-01
Penalties and ownership
What sits behind the stars
$14,901
2025-03-19
Fine
Fine · fine $14,901
Fine
Ownership
Floyd C Eaton Iii Trust 2012
5% Or Greater Indirect Ownership Interest · Organization
James Brett Klausman Trust 2012
5% Or Greater Indirect Ownership Interest · Organization
Jamie N Eaton Trust 2012
5% Or Greater Indirect Ownership Interest · Organization
Michael Graham Klausman Trust 2012
5% Or Greater Indirect Ownership Interest · Organization
Eaton, Floyd
5% Or Greater Direct Ownership Interest · Individual
Eaton, Floyd
5% Or Greater Indirect Ownership Interest · Individual
Eaton, Floyd
Operational/Managerial Control · Individual
Eaton, Floyd
Corporate Director · Individual
Klaton Enterprises, LLC
5% Or Greater Direct Ownership Interest · Organization
Klausman, James
5% Or Greater Indirect Ownership Interest · Individual
Klausman, James
Operational/Managerial Control · Individual
Klausman, James
Corporate Director · Individual
Midwest Health, Inc. 06122001
Operational/Managerial Control · Organization
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Lawrence Presbyterian Manor
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5-star overall rating with 4-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Lawrence Memorial Hospital SNF
Lawrence, KS
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Medicalodges Eudora
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1-star overall rating with 1-star inspections with abuse icon flag with $14,901 in total fines with 23 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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