Cycle 1
Health 2025-11-17 · Fire 2025-11-17
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Overland Park, KS
Stratford Commons Rehab & Health Care Center
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
12340 Quivira Road, Overland Park, KS
(913) 851-0215
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
52
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Tutera Senior Living & Health Care
Operator or chain grouping
Approved since
2015-11-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
25 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.59
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.38
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.93
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.58
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.26
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
3.73
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,737
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.49
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.87
Baseline 22.69% · Performance 21.92% · Measure score 0.87 · Achievement 0 · Improvement 0.87
Healthcare-associated infections
1.40
Baseline 6.38% · Performance 7.41% · Measure score 1.40 · Achievement 1.40 · Improvement 0
Total nurse turnover
1.68
Performance 56.82% · Measure score 1.68 · Achievement 1.68 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.24
Baseline 4.54 hours · Performance 3.72 hours · Measure score 2.24 · Achievement 2.24 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.23% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 131 · Observed rate 13.74% · Lower 95% interval 8.23% |
| Discharge to community | 50.25% |
50.57%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 133 · Observed rate 42.11% · Lower 95% interval 43.23% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 88 · Denominator 88 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 88 |
| Discharge self-care score | 55.56% |
53.69%
1.9 pts better
|
Numerator 30 · Denominator 54 |
| Discharge mobility score | 51.85% |
50.94%
0.9 pts better
|
Numerator 28 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 4.55% |
2.29%
2.3 pts worse
|
Numerator 4 · Denominator 88 · Adjusted rate 5.49% |
| Healthcare-associated infections requiring hospitalization | 7.41% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 85 · Observed rate 8.24% · Lower 95% interval 4.77% |
| Staff COVID-19 vaccination coverage | 3.92% |
8.2%
4.3 pts worse
|
Numerator 2 · Denominator 51 |
| Staff flu vaccination coverage | 58.33% |
42%
16.3 pts better
|
Numerator 63 · Denominator 108 |
| Discharge function score | 55.56% |
56.45%
0.9 pts worse
|
Numerator 30 · Denominator 54 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 32 · Denominator 32 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 44 · Denominator 44 |
| Resident COVID-19 vaccinations up to date | 43.75% |
25.2%
18.6 pts better
|
Numerator 21 · Denominator 48 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 | 97.7% |
95.5%
2.2 pts better
|
95.5%
2.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.3% |
4.4%
0.1 pts better
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 2.8% · Q3 2.8% · Q4 2.9% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.1% |
5.6%
2.5 pts better
|
11.4%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 5.7% · Q4 3.3% · 4Q avg 3.1% |
| Percentage of long-stay residents who lose too much weight | 1.7% |
5.0%
3.3 pts better
|
5.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.3% · Q4 3.6% · 4Q avg 1.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.0% |
23.2%
8.8 pts worse
|
19.6%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 28.1% · Q3 32.3% · Q4 27.6% · 4Q avg 32.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.1% |
19.8%
8.7 pts better
|
16.7%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 11.5% · Q3 8.0% · Q4 16.0% · 4Q avg 11.1% · 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 | 12.5% |
18.4%
5.9 pts better
|
16.3%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.6% |
18.8%
0.8 pts worse
|
14.9%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 21.4% · Q3 14.8% · Q4 20.0% · 4Q avg 19.6% · 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 | 4.4% |
3.1%
1.3 pts worse
|
1.7%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 2.9% · Q3 2.9% · Q4 3.1% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.7% |
23.2%
7.5 pts better
|
19.8%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 7.8% · Q3 15.9% · Q4 32.8% · 4Q avg 15.7% |
| Percentage of long-stay residents with pressure ulcers | 8.2% |
4.6%
3.6 pts worse
|
5.1%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 14.6% · Q3 4.2% · Q4 5.0% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.3% |
75.6%
20.7 pts better
|
81.7%
14.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.9% · Q2 97.7% · Q3 97.7% · Q4 96.7% · 4Q avg 96.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.3% |
11.7%
2.4 pts better
|
12.0%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.3% · Observed 11.0% · Expected 13.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
2.2%
1.1 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.8% · Q3 1.7% · Q4 0.8% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.8% |
73.5%
24.3 pts better
|
79.7%
18.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.6% |
23.0%
2.6 pts worse
|
23.9%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.6% · Observed 28.0% · Expected 26.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-08 · Fire 2024-02-08
17 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-07-28 · Fire 2022-07-28
19 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-11-17
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2026-02-19
F · Potential for more than minimal harm
2025-11-17
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2026-02-19
F · Potential for more than minimal harm
2025-11-17
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2026-02-19
F · Potential for more than minimal harm
2025-11-17
E42 · Emergency Preparedness Deficiencies
Fire Safety
Meet the requirements of an integrated health system.
Corrected 2026-02-19
F · Potential for more than minimal harm
2025-11-17
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2026-02-19
F · Potential for more than minimal harm
2025-11-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-02-19
F · Potential for more than minimal harm
2025-11-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-19
F · Potential for more than minimal harm
2025-11-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-02-19
F · Potential for more than minimal harm
2025-11-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-02-19
E · Potential for more than minimal harm
2025-11-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-02-19
E · Potential for more than minimal harm
2025-11-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2026-02-19
F · Potential for more than minimal harm
2024-02-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-27
F · Potential for more than minimal harm
2024-02-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-27
F · Potential for more than minimal harm
2024-02-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-27
F · Potential for more than minimal harm
2024-02-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-27
E · Potential for more than minimal harm
2024-02-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-27
E · Potential for more than minimal harm
2024-02-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-27
E · Potential for more than minimal harm
2024-02-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-02-08
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-02-08
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-02-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-02-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-27
F · Potential for more than minimal harm
2022-07-28
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-07-28
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-07-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-07-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-07-28
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-07-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-07-28
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-07-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-07-28
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-07-28
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 2022-10-10
F · Potential for more than minimal harm
2022-07-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-10
E · Potential for more than minimal harm
2022-07-28
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 2022-10-10
D · Potential for more than minimal harm
2022-07-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-10-10
Inspection history
Recent health citations
J · Immediate jeopardy
2025-11-18
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 2025-10-20
E · Potential for more than minimal harm
2025-11-17
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 2025-11-21
E · Potential for more than minimal harm
2025-11-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-11-17
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 2025-11-21
D · Potential for more than minimal harm
2025-11-17
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-09-07
D · Potential for more than minimal harm
2025-11-17
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-11-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-11-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-11-17
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-11-21
F · Potential for more than minimal harm
2024-02-08
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 2024-03-11
F · Potential for more than minimal harm
2024-02-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-11
E · Potential for more than minimal harm
2024-02-08
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 2024-03-11
D · Potential for more than minimal harm
2024-02-08
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 2024-03-11
D · Potential for more than minimal harm
2024-02-08
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-08
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 2024-03-11
D · Potential for more than minimal harm
2024-02-08
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 2024-03-11
D · Potential for more than minimal harm
2024-02-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-08
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-08
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 2024-03-11
D · Potential for more than minimal harm
2024-02-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-08
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-08
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-08
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-08
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 2024-03-11
D · Potential for more than minimal harm
2024-02-08
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-03-11
F · Potential for more than minimal harm
2022-07-28
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-08-29
E · Potential for more than minimal harm
2022-07-28
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 2022-08-29
E · Potential for more than minimal harm
2022-07-28
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 2022-08-29
E · Potential for more than minimal harm
2022-07-28
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-08-29
E · Potential for more than minimal harm
2022-07-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-29
E · Potential for more than minimal harm
2022-07-28
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-08-29
D · Potential for more than minimal harm
2022-07-28
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-08-29
D · Potential for more than minimal harm
2022-07-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-08-29
D · Potential for more than minimal harm
2022-07-28
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 2022-08-29
D · Potential for more than minimal harm
2022-07-28
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 2022-08-29
D · Potential for more than minimal harm
2022-07-28
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-08-29
D · Potential for more than minimal harm
2022-07-28
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-08-29
D · Potential for more than minimal harm
2022-07-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-08-29
D · Potential for more than minimal harm
2022-07-28
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-08-29
D · Potential for more than minimal harm
2022-07-28
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 2022-08-29
D · Potential for more than minimal harm
2022-07-28
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 2022-08-29
D · Potential for more than minimal harm
2022-07-28
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-08-29
D · Potential for more than minimal harm
2022-07-28
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 2022-08-29
D · Potential for more than minimal harm
2022-07-28
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2022-08-29
Penalties and ownership
What sits behind the stars
Ownership
Constace Marie Mendolia 2009 Irrv Tr
5% Or Greater Direct Ownership Interest · Organization
Joseph C Tutera 2009 Irrevocable Trust
5% Or Greater Direct Ownership Interest · Organization
Joseph Charles Tutera 2013 Family Irrevociable Trust Agreement
5% Or Greater Direct Ownership Interest · Organization
Mary Margaret Cunningham 2009 Irrv Tr
5% Or Greater Direct Ownership Interest · Organization
Tutera, Joseph
5% Or Greater Direct Ownership Interest · Individual
Bloom, Randall
Operational/Managerial Control · Individual
Brooks, Kiley
Operational/Managerial Control · Individual
Brooks, Kiley
Corporate Officer · Individual
Cunningham, Mary
5% Or Greater Direct Ownership Interest · Individual
Flanagan, Michael
Contracted Managing Employee · Individual
Mendolia, Constance
5% Or Greater Direct Ownership Interest · Individual
Tutera Investments, LLC
Operational/Managerial Control · Organization
Tutera, Joseph
Corporate Officer · Individual
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