Cycle 1
Health 2024-09-18 · Fire 2024-09-18
24 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Shawnee, KS
Shawnee Gardens Healthcare & Rehab Center
1-star overall rating with 1-star inspections with abuse icon flag with $94,968 in total fines with 24 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
6416 Long Street, Shawnee, KS
(913) 631-2146
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
130
Certified beds
Average residents
107
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Recover-Care Healthcare
Operator or chain grouping
Approved since
1993-12-01
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
0.41
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.16
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.43
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.28
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
3.07
CMS adjusted total nurse staffing hours
Case-mix index
1.53
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
72%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,112
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.36
Composite VBP score used to determine payment impact.
Payment multiplier
0.9906
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
9.30
Baseline 18.51% · Performance 17.12% · Measure score 9.30 · Achievement 9.30 · Improvement 8.86
Healthcare-associated infections
4.78
Baseline 6.20% · Performance 6.41% · Measure score 4.78 · Achievement 4.78 · Improvement 0
Total nurse turnover
0
Baseline 61.26% · Performance 67.50% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.87
Baseline 3.64 hours · Performance 3.33 hours · Measure score 0.87 · Achievement 0.87 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.88% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 98 · Observed rate 8.16% · Lower 95% interval 6.33% |
| Discharge to community | 28.48% |
50.57%
22.1 pts worse
|
Worse than the National Rate · Eligible stays 53 · Observed rate 15.09% · Lower 95% interval 18.99% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 35.82% |
95.27%
59.4 pts worse
|
Numerator 24 · Denominator 67 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 67 |
| Discharge self-care score | 44.07% |
53.69%
9.6 pts worse
|
Numerator 26 · Denominator 59 |
| Discharge mobility score | 23.73% |
50.94%
27.2 pts worse
|
Numerator 14 · Denominator 59 |
| Pressure ulcers or injuries, new or worsened | 2.99% |
2.29%
0.7 pts worse
|
Numerator 2 · Denominator 67 · Adjusted rate 3.21% |
| Healthcare-associated infections requiring hospitalization | 6.41% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 3.85% · Lower 95% interval 3.35% |
| Staff COVID-19 vaccination coverage | 15% |
8.2%
6.8 pts better
|
Numerator 21 · Denominator 140 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 33.9% |
56.45%
22.6 pts worse
|
Numerator 20 · Denominator 59 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 27.5% |
25.2%
2.3 pts better
|
Numerator 11 · Denominator 40 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
1.8
0.8 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.3 · Expected 1.7 · 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 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 52.9% |
91.8%
38.9 pts worse
|
93.4%
40.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 64.1% · Q2 55.8% · Q3 48.5% · Q4 42.6% · 4Q avg 52.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.5% |
95.5%
5 pts worse
|
95.5%
5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
4.4%
1.5 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.5% · Q3 2.9% · Q4 2.0% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 16.2% |
5.6%
10.6 pts worse
|
11.4%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 21.6% · Q3 17.5% · Q4 4.3% · 4Q avg 16.2% |
| Percentage of long-stay residents who lose too much weight | 19.9% |
5.0%
14.9 pts worse
|
5.4%
14.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 18.0% · Q3 34.1% · Q4 22.0% · 4Q avg 19.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.1% |
23.2%
2.9 pts worse
|
19.6%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 28.7% · Q3 25.3% · Q4 27.1% · 4Q avg 26.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.7% |
19.8%
6.1 pts better
|
16.7%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 18.8% · Q3 14.3% · Q4 12.3% · 4Q avg 13.7% · 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 | 21.3% |
18.4%
2.9 pts worse
|
16.3%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.1% · Q2 31.1% · Q3 11.2% · Q4 13.8% · 4Q avg 21.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.1% |
18.8%
0.3 pts worse
|
14.9%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 35.6% · Q3 11.8% · Q4 6.1% · 4Q avg 19.1% · 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 | 3.2% |
3.1%
0.1 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.9% · Q3 5.0% · Q4 3.1% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.0% |
23.2%
2.8 pts worse
|
19.8%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.2% · Q2 26.5% · Q3 23.0% · Q4 26.3% · 4Q avg 26.0% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
4.6%
0.5 pts worse
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 7.6% · Q3 4.8% · Q4 3.7% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 30.8% |
75.6%
44.8 pts worse
|
81.7%
50.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 55.1% · Q2 32.4% · Q3 14.5% · Q4 13.4% · 4Q avg 30.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.0% |
11.7%
6.7 pts better
|
12.0%
7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.0% · Observed 5.7% · Expected 12.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
2.2%
0.8 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.5% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 42.7% |
73.5%
30.8 pts worse
|
79.7%
37 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 42.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.5% |
23.0%
6.5 pts better
|
23.9%
7.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.5% · Observed 17.0% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-24 · Fire 2023-01-24
22 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2021-06-10 · Fire 2021-06-10
14 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
L · Immediate jeopardy
2024-12-16
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 2024-12-30
F · Potential for more than minimal harm
2024-09-18
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-09-18
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-09-18
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-09-18
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-11-15
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-27
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-08-20
G · Actual harm
2025-06-11
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2025-07-09
G · Actual harm
2025-06-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-09
J · Immediate jeopardy
2025-02-19
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 2025-03-18
G · Actual harm
2025-02-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-18
D · Potential for more than minimal harm
2025-02-19
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-03-18
F · Potential for more than minimal harm
2024-09-18
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2024-10-21
F · Potential for more than minimal harm
2024-09-18
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2024-10-21
F · Potential for more than minimal harm
2024-09-18
F942 · Resident Rights Deficiencies
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2024-10-21
F · Potential for more than minimal harm
2024-09-18
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2024-10-21
E · Potential for more than minimal harm
2024-09-18
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-10-21
E · Potential for more than minimal harm
2024-09-18
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 2024-10-21
E · Potential for more than minimal harm
2024-09-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-09-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-09-18
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-09-18
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 2024-10-21
D · Potential for more than minimal harm
2024-09-18
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-09-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-09-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-09-18
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-09-18
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 2024-10-21
D · Potential for more than minimal harm
2024-09-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-09-18
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-09-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-09-18
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 2024-10-21
D · Potential for more than minimal harm
2024-09-18
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-10-21
C · Minimal harm
2024-09-18
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-10-21
G · Actual harm
2024-05-01
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 2024-05-24
G · Actual harm
2023-12-11
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 2023-12-20
D · Potential for more than minimal harm
2023-09-14
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-05-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-15
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-04-11
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-05-24
F · Potential for more than minimal harm
2023-01-24
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 2023-03-23
E · Potential for more than minimal harm
2023-01-24
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 2023-03-23
E · Potential for more than minimal harm
2023-01-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-23
D · Potential for more than minimal harm
2023-01-24
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-03-23
D · Potential for more than minimal harm
2023-01-24
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-03-23
D · Potential for more than minimal harm
2023-01-24
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-03-23
D · Potential for more than minimal harm
2023-01-24
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-03-23
D · Potential for more than minimal harm
2023-01-24
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 2023-03-23
D · Potential for more than minimal harm
2023-01-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-23
D · Potential for more than minimal harm
2023-01-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-23
D · Potential for more than minimal harm
2023-01-24
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 2023-03-23
D · Potential for more than minimal harm
2023-01-24
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 2023-03-23
D · Potential for more than minimal harm
2023-01-24
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 2023-03-23
D · Potential for more than minimal harm
2023-01-24
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-03-23
D · Potential for more than minimal harm
2023-01-24
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-03-23
D · Potential for more than minimal harm
2023-01-24
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 2023-03-23
D · Potential for more than minimal harm
2023-01-24
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 2023-03-23
D · Potential for more than minimal harm
2023-01-24
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 2023-03-23
F · Potential for more than minimal harm
2021-06-10
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2021-07-13
F · Potential for more than minimal harm
2021-06-10
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2021-07-13
F · Potential for more than minimal harm
2021-06-10
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 2021-07-13
D · Potential for more than minimal harm
2021-06-10
F608 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.
Corrected 2021-07-13
D · Potential for more than minimal harm
2021-06-10
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 2021-07-13
D · Potential for more than minimal harm
2021-06-10
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2021-07-13
D · Potential for more than minimal harm
2021-06-10
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 2021-07-13
D · Potential for more than minimal harm
2021-06-10
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 2021-07-13
Penalties and ownership
What sits behind the stars
$40,180
2025-06-11
Fine
Fine · fine $40,180
Fine
$16,452
2025-02-19
Fine
Fine · fine $16,452
Fine
$12,561
2024-10-08
Fine
Fine · fine $12,561
Fine
$25,775
2024-05-01
Fine
Fine · fine $25,775
Fine
Ownership
Midwest Recover-Care LLC
5% Or Greater Direct Ownership Interest · Organization
Bhnv 2 LLC
5% Or Greater Indirect Ownership Interest · Organization
Frisbie, Karen
Operational/Managerial Control · Individual
Goldstein, Avrohom
5% Or Greater Indirect Ownership Interest · Individual
Kansas SNF Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Mad Family Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Margulies, Zisha
5% Or Greater Indirect Ownership Interest · Individual
Mrc SNF Management LLC
Operational/Managerial Control · Organization
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
Recover-Care Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Rnr Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Smith, Cameron
Operational/Managerial Control · Individual
Wetr Trust
5% Or Greater Indirect Ownership Interest · Organization
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Brookdale Rosehill
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5-star overall rating with 3-star inspections with 5 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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