Cycle 1
Health 2024-11-07 · Fire 2024-11-07
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
20 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Wichita, KS
Sandpiper Healthcare & Rehabilitation Center
4-star overall rating with 3-star inspections with $16,801 in total fines with 9 recent health deficiencies with 20 fire-safety deficiencies in the latest cycle
5808 W 8th Street North, Wichita, KS
(316) 945-3606
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
104
Certified beds
Average residents
76
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Recover-Care Healthcare
Operator or chain grouping
Approved since
1995-05-01
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
0.70
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.65
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.06
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.55
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.64
CMS adjusted RN staffing hours
Adjusted total hours
3.74
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,492
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.52
Composite VBP score used to determine payment impact.
Payment multiplier
0.9832
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.61
Baseline 17.06% · Performance 18.83% · Measure score 5.61 · Achievement 5.61 · Improvement 0
Healthcare-associated infections
1.63
Baseline 6.86% · Performance 7.35% · Measure score 1.63 · Achievement 1.63 · Improvement 0
Total nurse turnover
0
Baseline 58.03% · Performance 67.35% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.17
Baseline 3.29 hours · Performance 3.69 hours · Measure score 2.17 · Achievement 2.17 · Improvement 1.11
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.31% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 89 · Observed rate 6.74% · Lower 95% interval 6.3% |
| Discharge to community | 54% |
50.57%
3.4 pts better
|
No Different than the National Rate · Eligible stays 66 · Observed rate 45.45% · Lower 95% interval 39.1% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 71 · Denominator 71 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 71 |
| Discharge self-care score | 42.11% |
53.69%
11.6 pts worse
|
Numerator 24 · Denominator 57 |
| Discharge mobility score | 47.37% |
50.94%
3.6 pts worse
|
Numerator 27 · Denominator 57 |
| Pressure ulcers or injuries, new or worsened | 2.82% |
2.29%
0.5 pts worse
|
Numerator 2 · Denominator 71 · Adjusted rate 2.95% |
| Healthcare-associated infections requiring hospitalization | 7.35% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 45 · Observed rate 8.89% · Lower 95% interval 4.16% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 102 |
| Staff flu vaccination coverage | 16.35% |
42%
25.6 pts worse
|
Numerator 17 · Denominator 104 |
| Discharge function score | 49.12% |
56.45%
7.3 pts worse
|
Numerator 28 · Denominator 57 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 36 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 24.32% |
25.2%
0.9 pts worse
|
Numerator 9 · Denominator 37 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.8
1.1 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.9 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0 |
2.2
2.2 pts better
|
1.8
1.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0 · Observed 0 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.8%
8.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.5%
4.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.4% |
4.4%
4 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.9% |
5.6%
0.3 pts worse
|
11.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 1.8% · Q3 11.1% · Q4 5.3% · 4Q avg 5.9% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
5.0%
2.2 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 2.0% · Q3 1.9% · Q4 3.5% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.5% |
23.2%
3.7 pts better
|
19.6%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 21.2% · Q3 20.0% · Q4 15.3% · 4Q avg 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.9% |
19.8%
6.9 pts better
|
16.7%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 10.0% · Q3 15.4% · Q4 11.6% · 4Q avg 12.9% · 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 | 13.9% |
18.4%
4.5 pts better
|
16.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 4.5% · Q3 14.6% · Q4 18.6% · 4Q avg 13.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.5% |
18.8%
9.3 pts better
|
14.9%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 4.1% · Q3 11.5% · Q4 6.9% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.8%
1.8 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 8.1% |
3.1%
5 pts worse
|
1.7%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 8.6% · Q3 5.3% · Q4 6.6% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.8% |
23.2%
14.4 pts better
|
19.8%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 7.8% · Q3 10.8% · Q4 1.8% · 4Q avg 8.8% |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
4.6%
2.9 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 9.4% · Q3 5.4% · Q4 7.8% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
75.6%
23.3 pts better
|
81.7%
17.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 100.0% · Q3 99.2% · Q4 98.1% · 4Q avg 98.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
11.7%
11.7 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 10.8% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 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 | 96.2% |
73.5%
22.7 pts better
|
79.7%
16.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 10.6% |
23.0%
12.4 pts better
|
23.9%
13.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.6% · Observed 10.2% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-05 · Fire 2023-01-05
10 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
19 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Cycle 3
Health 2021-02-04 · Fire 2021-02-04
13 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
L · Immediate jeopardy
2024-11-07
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2024-12-12
L · Immediate jeopardy
2024-11-07
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-12-12
L · Immediate jeopardy
2024-11-07
K251 · Egress Deficiencies
Fire Safety
Conform to length requirements for dead end corridors.
Corrected 2024-12-12
F · Potential for more than minimal harm
2024-11-07
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-12-12
F · Potential for more than minimal harm
2024-11-07
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-12-12
F · Potential for more than minimal harm
2024-11-07
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-12-12
F · Potential for more than minimal harm
2024-11-07
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-12-18
F · Potential for more than minimal harm
2024-11-07
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-12-12
F · Potential for more than minimal harm
2024-11-07
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-12-18
F · Potential for more than minimal harm
2024-11-07
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-12-19
F · Potential for more than minimal harm
2024-11-07
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-12-12
F · Potential for more than minimal harm
2024-11-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-18
F · Potential for more than minimal harm
2024-11-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-12
F · Potential for more than minimal harm
2024-11-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-19
F · Potential for more than minimal harm
2024-11-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-18
F · Potential for more than minimal harm
2024-11-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-18
F · Potential for more than minimal harm
2024-11-07
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-12
F · Potential for more than minimal harm
2024-11-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-12
F · Potential for more than minimal harm
2024-11-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-18
E · Potential for more than minimal harm
2024-11-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-12-12
F · Potential for more than minimal harm
2024-07-31
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2024-08-08
F · Potential for more than minimal harm
2024-07-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-08
F · Potential for more than minimal harm
2024-07-31
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-08-08
F · Potential for more than minimal harm
2023-01-05
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 2023-03-10
F · Potential for more than minimal harm
2023-01-05
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-03-10
F · Potential for more than minimal harm
2023-01-05
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 2023-03-10
F · Potential for more than minimal harm
2023-01-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-10
F · Potential for more than minimal harm
2023-01-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-10
F · Potential for more than minimal harm
2023-01-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-10
F · Potential for more than minimal harm
2023-01-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-10
F · Potential for more than minimal harm
2023-01-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-10
F · Potential for more than minimal harm
2023-01-05
K771 · Miscellaneous Deficiencies
Fire Safety
Ensure that smoke control systems are tested and documented in accordance with established engineering principles.
Corrected 2023-03-10
F · Potential for more than minimal harm
2023-01-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-10
F · Potential for more than minimal harm
2023-01-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-03-10
E · Potential for more than minimal harm
2023-01-05
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-03-10
E · Potential for more than minimal harm
2023-01-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-10
E · Potential for more than minimal harm
2023-01-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-10
E · Potential for more than minimal harm
2023-01-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-01-05
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 2023-03-10
F · Potential for more than minimal harm
2021-02-04
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2021-04-15
F · Potential for more than minimal harm
2021-02-04
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2021-04-15
F · Potential for more than minimal harm
2021-02-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-04-15
F · Potential for more than minimal harm
2021-02-04
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2021-04-15
F · Potential for more than minimal harm
2021-02-04
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2021-04-15
F · Potential for more than minimal harm
2021-02-04
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2021-04-15
F · Potential for more than minimal harm
2021-02-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-04-15
F · Potential for more than minimal harm
2021-02-04
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-04-15
F · Potential for more than minimal harm
2021-02-04
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 2021-04-15
F · Potential for more than minimal harm
2021-02-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-04-15
F · Potential for more than minimal harm
2021-02-04
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-04-15
E · Potential for more than minimal harm
2021-02-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-04-15
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-11-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-29
E · Potential for more than minimal harm
2024-11-07
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-11-29
E · Potential for more than minimal harm
2024-11-07
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-11-07
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 2024-11-29
D · Potential for more than minimal harm
2024-11-07
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 2024-11-29
D · Potential for more than minimal harm
2024-11-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-11-07
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 2024-11-29
D · Potential for more than minimal harm
2024-11-07
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 2024-11-29
D · Potential for more than minimal harm
2024-11-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-29
F · Potential for more than minimal harm
2024-04-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-04-16
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 2024-05-01
F · Potential for more than minimal harm
2023-11-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-27
F · Potential for more than minimal harm
2023-01-05
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-01-16
F · Potential for more than minimal harm
2023-01-05
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 2023-01-16
D · Potential for more than minimal harm
2023-01-05
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 2023-01-16
D · Potential for more than minimal harm
2023-01-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-01-16
D · Potential for more than minimal harm
2023-01-05
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 2023-01-16
D · Potential for more than minimal harm
2023-01-05
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 2023-01-16
D · Potential for more than minimal harm
2023-01-05
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 2023-01-16
D · Potential for more than minimal harm
2023-01-05
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2023-01-16
F · Potential for more than minimal harm
2021-02-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-02-26
E · Potential for more than minimal harm
2021-02-04
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2021-02-26
E · Potential for more than minimal harm
2021-02-04
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2021-02-26
E · Potential for more than minimal harm
2021-02-04
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-02-26
D · Potential for more than minimal harm
2021-02-04
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2021-02-26
D · Potential for more than minimal harm
2021-02-04
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 2021-02-26
D · Potential for more than minimal harm
2021-02-04
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2021-02-26
D · Potential for more than minimal harm
2021-02-04
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 2021-02-26
D · Potential for more than minimal harm
2021-02-04
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-02-26
D · Potential for more than minimal harm
2021-02-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-02-26
D · Potential for more than minimal harm
2021-02-04
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-02-26
C · Minimal harm
2021-02-04
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2021-02-26
Penalties and ownership
What sits behind the stars
$16,801
2024-12-03
Fine
Fine · fine $16,801
Fine
Ownership
Natr Trust
5% Or Greater Indirect Ownership Interest · Organization
Rarmna Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Ratr Trust
5% Or Greater Indirect Ownership Interest · Organization
Rnr Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Wetr Trust
5% Or Greater Indirect Ownership Interest · Organization
Ayesh, Tiffany
Operational/Managerial Control · Individual
Knight, Denis
Operational/Managerial Control · Individual
Margulies, Zisha
Operational/Managerial Control · Individual
Mrc SNF Management LLC
Operational/Managerial Control · Organization
Reicks, Danielle
Operational/Managerial Control · Individual
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