Cycle 1
Health 2025-03-19 · Fire 2025-03-19
21 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
20 fire-safety deficiencies
Top issue: Smoke (9 deficiencies)
Topeka, KS
Plaza West Healthcare And Rehab
1-star overall rating with 1-star inspections with $93,073 in total fines with 21 recent health deficiencies with 20 fire-safety deficiencies in the latest cycle
1570 Sw Westport Drive, Topeka, KS
(785) 271-6700
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
151
Certified beds
Average residents
125
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Recover-Care Healthcare
Operator or chain grouping
Approved since
1993-05-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
25 facilities
Chain averages 3 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
0.39
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.61
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.74
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.74
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.00
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.91
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.35
CMS adjusted RN staffing hours
Adjusted total hours
3.33
CMS adjusted total nurse staffing hours
Case-mix index
1.54
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
66%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,480
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.64
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.42% · Performance 23.12% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.37
Baseline 7.18% · Performance 6.83% · Measure score 3.37 · Achievement 3.37 · Improvement 1.11
Total nurse turnover
1.34
Baseline 65.12% · Performance 58.21% · Measure score 1.34 · Achievement 1.34 · Improvement 1.22
Adjusted total nurse staffing
1.95
Baseline 3.08 hours · Performance 3.63 hours · Measure score 1.95 · Achievement 1.95 · Improvement 1.54
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.28% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 290 · Observed rate 12.41% · Lower 95% interval 8.32% |
| Discharge to community | 54.49% |
50.57%
3.9 pts better
|
No Different than the National Rate · Eligible stays 233 · Observed rate 48.5% · Lower 95% interval 46.93% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 95.18% |
95.27%
0.1 pts worse
|
Numerator 158 · Denominator 166 |
| Falls with major injury | 0.6% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 166 |
| Discharge self-care score | 39.45% |
53.69%
14.2 pts worse
|
Numerator 43 · Denominator 109 |
| Discharge mobility score | 37.61% |
50.94%
13.3 pts worse
|
Numerator 41 · Denominator 109 |
| Pressure ulcers or injuries, new or worsened | 2.41% |
2.29%
0.1 pts worse
|
Numerator 4 · Denominator 166 · Adjusted rate 2.42% |
| Healthcare-associated infections requiring hospitalization | 6.83% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 138 · Observed rate 6.52% · Lower 95% interval 4.35% |
| Staff COVID-19 vaccination coverage | 16.77% |
8.2%
8.6 pts better
|
Numerator 27 · Denominator 161 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 50.46% |
56.45%
6 pts worse
|
Numerator 55 · Denominator 109 |
| Transfer of health information to provider | 95.56% |
95.95%
0.4 pts worse
|
Numerator 43 · Denominator 45 |
| Transfer of health information to patient | 97.4% |
96.28%
1.1 pts better
|
Numerator 75 · Denominator 77 |
| Resident COVID-19 vaccinations up to date | 16.48% |
25.2%
8.7 pts worse
|
Numerator 15 · Denominator 91 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.8
0.7 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.2 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
2.2
0.3 pts better
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.8 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 86.1% |
91.8%
5.7 pts worse
|
93.4%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 88.1% · Q2 89.1% · Q3 83.2% · Q4 84.0% · 4Q avg 86.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 76.7% |
95.5%
18.8 pts worse
|
95.5%
18.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 76.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.5% |
4.4%
0.9 pts better
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 3.0% · Q3 4.7% · Q4 3.8% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
5.6%
3.7 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 3.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 4.4% |
5.0%
0.6 pts better
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 6.2% · Q3 2.4% · Q4 1.1% · 4Q avg 4.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.1% |
23.2%
3.1 pts better
|
19.6%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 17.9% · Q3 18.2% · Q4 21.7% · 4Q avg 20.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.7% |
19.8%
0.9 pts worse
|
16.7%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 18.8% · Q3 20.5% · Q4 22.2% · 4Q avg 20.7% · 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 | 15.6% |
18.4%
2.8 pts better
|
16.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 15.4% · Q3 12.6% · Q4 4.7% · 4Q avg 15.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.3% |
18.8%
7.5 pts better
|
14.9%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 11.4% · Q3 8.3% · Q4 4.6% · 4Q avg 11.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.1% |
1.8%
1.3 pts worse
|
1.0%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 2.5% · Q3 3.1% · Q4 2.8% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
3.1%
2.1 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.0% |
23.2%
3.8 pts worse
|
19.8%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 34.0% · Q3 21.9% · Q4 25.3% · 4Q avg 27.0% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
4.6%
0.9 pts worse
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 3.7% · Q3 4.5% · Q4 7.7% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 46.2% |
75.6%
29.4 pts worse
|
81.7%
35.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 50.6% · Q2 38.3% · Q3 40.9% · Q4 58.0% · 4Q avg 46.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.1% |
11.7%
4.4 pts worse
|
12.0%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.1% · Observed 18.6% · Expected 12.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
2.2%
About the same
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.6% · Q3 1.1% · Q4 1.4% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 44.1% |
73.5%
29.4 pts worse
|
79.7%
35.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 44.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.5% |
23.0%
3.5 pts worse
|
23.9%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.5% · Observed 28.6% · Expected 25.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-09 · Fire 2023-10-09
27 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
19 fire-safety deficiencies
Top issue: Smoke (9 deficiencies)
Cycle 3
Health 2022-04-21 · Fire 2022-04-21
21 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
31 fire-safety deficiencies
Top issue: Smoke (10 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-19
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-05-16
F · Potential for more than minimal harm
2025-03-19
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-05-16
F · Potential for more than minimal harm
2025-03-19
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-05-16
F · Potential for more than minimal harm
2025-03-19
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-05-16
F · Potential for more than minimal harm
2025-03-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-16
F · Potential for more than minimal harm
2025-03-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-15
F · Potential for more than minimal harm
2025-03-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-16
F · Potential for more than minimal harm
2025-03-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-16
F · Potential for more than minimal harm
2025-03-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-15
E · Potential for more than minimal harm
2025-03-19
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-05-16
E · Potential for more than minimal harm
2025-03-19
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-05-16
E · Potential for more than minimal harm
2025-03-19
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 2025-05-16
E · Potential for more than minimal harm
2025-03-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-16
E · Potential for more than minimal harm
2025-03-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-05-16
E · Potential for more than minimal harm
2025-03-19
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-05-16
E · Potential for more than minimal harm
2025-03-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-16
E · Potential for more than minimal harm
2025-03-19
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-05-16
E · Potential for more than minimal harm
2025-03-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-16
E · Potential for more than minimal harm
2025-03-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-05-16
E · Potential for more than minimal harm
2025-03-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-16
F · Potential for more than minimal harm
2023-10-09
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-12-19
F · Potential for more than minimal harm
2023-10-09
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-12-19
F · Potential for more than minimal harm
2023-10-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-19
F · Potential for more than minimal harm
2023-10-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-19
F · Potential for more than minimal harm
2023-10-09
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-12-19
F · Potential for more than minimal harm
2023-10-09
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-12-19
F · Potential for more than minimal harm
2023-10-09
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-12-19
F · Potential for more than minimal harm
2023-10-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-19
F · Potential for more than minimal harm
2023-10-09
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2023-12-19
F · Potential for more than minimal harm
2023-10-09
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 2023-12-19
F · Potential for more than minimal harm
2023-10-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-19
E · Potential for more than minimal harm
2023-10-09
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-12-19
E · Potential for more than minimal harm
2023-10-09
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 2023-12-19
E · Potential for more than minimal harm
2023-10-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-19
E · Potential for more than minimal harm
2023-10-09
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-12-19
E · Potential for more than minimal harm
2023-10-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-19
E · Potential for more than minimal harm
2023-10-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-12-19
E · Potential for more than minimal harm
2023-10-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-12-19
E · Potential for more than minimal harm
2023-10-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-19
F · Potential for more than minimal harm
2023-09-15
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 2023-09-19
F · Potential for more than minimal harm
2023-08-31
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-09-08
F · Potential for more than minimal harm
2022-04-21
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2022-06-11
F · Potential for more than minimal harm
2022-04-21
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2022-06-11
F · Potential for more than minimal harm
2022-04-21
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2022-06-11
F · Potential for more than minimal harm
2022-04-21
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2022-06-11
F · Potential for more than minimal harm
2022-04-21
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2022-06-11
F · Potential for more than minimal harm
2022-04-21
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-06-11
F · Potential for more than minimal harm
2022-04-21
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2022-06-11
F · Potential for more than minimal harm
2022-04-21
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2022-06-11
F · Potential for more than minimal harm
2022-04-21
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-06-11
F · Potential for more than minimal harm
2022-04-21
K163 · Construction Deficiencies
Fire Safety
Install noncombustible or limited-combustible interior walls.
Corrected 2022-06-11
F · Potential for more than minimal harm
2022-04-21
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2022-06-11
F · Potential for more than minimal harm
2022-04-21
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 2022-06-11
F · Potential for more than minimal harm
2022-04-21
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2022-06-11
F · Potential for more than minimal harm
2022-04-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-06-11
F · Potential for more than minimal harm
2022-04-21
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2022-06-11
F · Potential for more than minimal harm
2022-04-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-06-11
F · Potential for more than minimal harm
2022-04-21
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-06-11
F · Potential for more than minimal harm
2022-04-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-06-11
F · Potential for more than minimal harm
2022-04-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-06-11
F · Potential for more than minimal harm
2022-04-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-06-11
F · Potential for more than minimal harm
2022-04-21
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 2022-06-11
E · Potential for more than minimal harm
2022-04-21
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 2022-06-11
E · Potential for more than minimal harm
2022-04-21
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-06-11
E · Potential for more than minimal harm
2022-04-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-06-11
E · Potential for more than minimal harm
2022-04-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-06-11
E · Potential for more than minimal harm
2022-04-21
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2022-06-11
E · Potential for more than minimal harm
2022-04-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-06-11
D · Potential for more than minimal harm
2022-04-21
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 2022-06-11
D · Potential for more than minimal harm
2022-04-21
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-06-11
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-19
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-03-19
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-03-19
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 2025-05-09
E · Potential for more than minimal harm
2025-03-19
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 2025-05-09
E · Potential for more than minimal harm
2025-03-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-03-19
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-03-19
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-03-19
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-03-19
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 2025-05-09
D · Potential for more than minimal harm
2025-03-19
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 2025-05-09
D · Potential for more than minimal harm
2025-03-19
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 2025-05-09
D · Potential for more than minimal harm
2025-03-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-03-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-03-19
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-03-19
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 2025-05-09
D · Potential for more than minimal harm
2025-03-19
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-03-19
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-03-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-03-19
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-03-19
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-03-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-01-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-21
E · Potential for more than minimal harm
2024-09-30
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2024-10-29
E · Potential for more than minimal harm
2024-09-30
F942 · Resident Rights Deficiencies
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2024-10-29
D · Potential for more than minimal harm
2024-09-30
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-10-29
D · Potential for more than minimal harm
2024-09-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-29
D · Potential for more than minimal harm
2023-12-28
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 2024-01-26
D · Potential for more than minimal harm
2023-12-28
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 2024-01-26
D · Potential for more than minimal harm
2023-12-28
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-01-26
G · Actual harm
2023-10-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-06
F · Potential for more than minimal harm
2023-10-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-06
E · Potential for more than minimal harm
2023-10-09
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-11-06
E · Potential for more than minimal harm
2023-10-09
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 2023-11-06
E · Potential for more than minimal harm
2023-10-09
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 2023-11-06
E · Potential for more than minimal harm
2023-10-09
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 2023-11-06
D · Potential for more than minimal harm
2023-10-09
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 2023-11-06
D · Potential for more than minimal harm
2023-10-09
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-10-09
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-10-09
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 2023-11-06
D · Potential for more than minimal harm
2023-10-09
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 2023-11-06
D · Potential for more than minimal harm
2023-10-09
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-10-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-10-09
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-10-09
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 2023-11-06
D · Potential for more than minimal harm
2023-10-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-10-09
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-10-09
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 2023-11-06
D · Potential for more than minimal harm
2023-10-09
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 2023-11-06
D · Potential for more than minimal harm
2023-10-09
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 2023-11-06
D · Potential for more than minimal harm
2023-10-09
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-11-06
C · Minimal harm
2023-10-09
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-11-06
E · Potential for more than minimal harm
2023-06-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-27
D · Potential for more than minimal harm
2023-06-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-27
D · Potential for more than minimal harm
2023-06-20
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-07-27
D · Potential for more than minimal harm
2023-06-20
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-07-27
E · Potential for more than minimal harm
2023-05-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-12
D · Potential for more than minimal harm
2023-05-30
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-07-12
F · Potential for more than minimal harm
2022-04-21
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-06-02
F · Potential for more than minimal harm
2022-04-21
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 2022-06-02
E · Potential for more than minimal harm
2022-04-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-06-02
D · Potential for more than minimal harm
2022-04-21
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 2022-06-02
D · Potential for more than minimal harm
2022-04-21
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-06-02
D · Potential for more than minimal harm
2022-04-21
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 2022-06-02
D · Potential for more than minimal harm
2022-04-21
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 2022-06-02
D · Potential for more than minimal harm
2022-04-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-06-02
D · Potential for more than minimal harm
2022-04-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-06-02
D · Potential for more than minimal harm
2022-04-21
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 2022-06-02
D · Potential for more than minimal harm
2022-04-21
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 2022-06-02
D · Potential for more than minimal harm
2022-04-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-06-02
Penalties and ownership
What sits behind the stars
$4,893
2024-02-20
Fine
Fine · fine $4,893
Fine
$4,893
2024-02-12
Fine
Fine · fine $4,893
Fine
$14,679
2024-01-22
Fine
Fine · fine $14,679
Fine
$4,516
2024-01-08
Fine
Fine · fine $4,516
Fine
$3,846
2024-01-02
Fine
Fine · fine $3,846
Fine
$9,440
2023-12-11
Fine
Fine · fine $9,440
Fine
$2,470
2023-11-20
Fine
Fine · fine $2,470
Fine
$2,117
2023-11-13
Fine
Fine · fine $2,117
Fine
$4,233
2023-10-23
Fine
Fine · fine $4,233
Fine
$41,986
2023-10-09
Fine
Fine · fine $41,986
Fine
Ownership
Hagen, Glenn
Operational/Managerial Control · Individual
Lyda, Debbie
Operational/Managerial Control · Individual
Margulies, Zisha
Operational/Managerial Control · Individual
Mrc SNF Management LLC
Operational/Managerial Control · Organization
Rider, James
Operational/Managerial Control · Individual
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#3
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