Cycle 1
Health 2024-07-10 · Fire 2024-07-10
18 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Kansas City, KS
The Healthcare Resort Of Kansas City
2-star overall rating with 2-star inspections with $28,834 in total fines with 18 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
8900 Parallel Parkway, Kansas City, KS
(913) 788-2100
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
62
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2015-10-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 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
0.64
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
3.31
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.76
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.12
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.63
CMS adjusted RN staffing hours
Adjusted total hours
4.70
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,201
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.05
Composite VBP score used to determine payment impact.
Payment multiplier
1.0053
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.99
Baseline 22.40% · Performance 18.92% · Measure score 5.99 · Achievement 5.43 · Improvement 5.99
Healthcare-associated infections
5.54
Baseline 6.84% · Performance 6.18% · Measure score 5.54 · Achievement 5.54 · Improvement 3.08
Total nurse turnover
3.38
Baseline 71.23% · Performance 53.25% · Measure score 3.38 · Achievement 2.55 · Improvement 3.38
Adjusted total nurse staffing
5.51
Baseline 4.33 hours · Performance 4.65 hours · Measure score 5.51 · Achievement 5.51 · Improvement 1.66
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.1% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 166 · Observed rate 13.25% · Lower 95% interval 8.34% |
| Discharge to community | 63.83% |
50.57%
13.3 pts better
|
Better than the National Rate · Eligible stays 153 · Observed rate 58.17% · Lower 95% interval 56.37% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 23.08% |
95.27%
72.2 pts worse
|
Numerator 18 · Denominator 78 |
| Falls with major injury | 1.28% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 78 |
| Discharge self-care score | 72.22% |
53.69%
18.5 pts better
|
Numerator 39 · Denominator 54 |
| Discharge mobility score | 59.26% |
50.94%
8.3 pts better
|
Numerator 32 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 6.49% |
2.29%
4.2 pts worse
|
Numerator 5 · Denominator 77 · Adjusted rate 5.9% |
| Healthcare-associated infections requiring hospitalization | 6.18% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 72 · Observed rate 4.17% · Lower 95% interval 3.92% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 107 |
| Staff flu vaccination coverage | 70.22% |
42%
28.2 pts better
|
Numerator 125 · Denominator 178 |
| Discharge function score | 75.93% |
56.45%
19.5 pts better
|
Numerator 41 · Denominator 54 |
| Transfer of health information to provider | 95% |
95.95%
1 pts worse
|
Numerator 38 · Denominator 40 |
| Transfer of health information to patient | 83.33% |
96.28%
13 pts worse
|
Numerator 20 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 15.15% |
25.2%
10 pts worse
|
Numerator 5 · Denominator 33 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
91.8%
6 pts better
|
93.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 97.9% · Q3 97.8% · Q4 100.0% · 4Q avg 97.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.8% |
95.5%
7.7 pts worse
|
95.5%
7.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
4.4%
0.7 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 8.5% · Q3 4.4% · Q4 2.5% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.1% |
5.6%
0.5 pts worse
|
11.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 8.3% · Q3 6.9% · Q4 6.2% · 4Q avg 6.1% |
| Percentage of long-stay residents who lose too much weight | 18.8% |
5.0%
13.8 pts worse
|
5.4%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 17.5% · Q3 19.5% · Q4 18.4% · 4Q avg 18.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.1% |
23.2%
9.1 pts better
|
19.6%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 16.7% · Q3 9.8% · Q4 15.8% · 4Q avg 14.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.8% |
19.8%
17 pts better
|
16.7%
13.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.3% · Q3 0.0% · Q4 4.8% · 4Q avg 2.8% · 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 | 10.5% |
18.4%
7.9 pts better
|
16.3%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.1% |
18.8%
4.7 pts better
|
14.9%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 17.5% · Q3 17.9% · Q4 8.1% · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.3% |
1.8%
0.5 pts worse
|
1.0%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.0% · Q3 3.8% · Q4 1.5% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
3.1%
2 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.0% |
23.2%
6.8 pts worse
|
19.8%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.1% · Q2 35.1% · Q3 25.2% · Q4 22.1% · 4Q avg 30.0% |
| Percentage of long-stay residents with pressure ulcers | 8.9% |
4.6%
4.3 pts worse
|
5.1%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 2.7% · Q3 9.9% · Q4 16.9% · 4Q avg 8.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.5% |
75.6%
2.9 pts better
|
81.7%
3.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 70.9% · Q2 77.6% · Q3 78.7% · Q4 85.7% · 4Q avg 78.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.9% |
11.7%
3.8 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 8.5% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
2.2%
1.9 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 72.8% |
73.5%
0.7 pts worse
|
79.7%
6.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 72.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.8% |
23.0%
1.2 pts better
|
23.9%
2.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.8% · Observed 22.5% · Expected 24.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-02 · Fire 2022-11-02
11 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-06-16 · Fire 2021-06-16
16 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
15 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-05
F · Potential for more than minimal harm
2024-07-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-05
F · Potential for more than minimal harm
2024-07-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-05
E · Potential for more than minimal harm
2024-07-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-05
E · Potential for more than minimal harm
2024-07-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-05
F · Potential for more than minimal harm
2022-11-02
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2023-04-26
F · Potential for more than minimal harm
2022-11-02
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-04-26
F · Potential for more than minimal harm
2022-11-02
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 2023-04-26
F · Potential for more than minimal harm
2022-11-02
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-04-26
F · Potential for more than minimal harm
2022-11-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-26
F · Potential for more than minimal harm
2022-11-02
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-04-26
F · Potential for more than minimal harm
2022-11-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-26
F · Potential for more than minimal harm
2022-11-02
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-04-26
F · Potential for more than minimal harm
2022-11-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-26
E · Potential for more than minimal harm
2022-11-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-26
F · Potential for more than minimal harm
2021-06-16
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2021-08-13
F · Potential for more than minimal harm
2021-06-16
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2021-08-13
F · Potential for more than minimal harm
2021-06-16
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2021-08-13
F · Potential for more than minimal harm
2021-06-16
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2021-08-13
F · Potential for more than minimal harm
2021-06-16
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 2021-08-13
F · Potential for more than minimal harm
2021-06-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-08-13
F · Potential for more than minimal harm
2021-06-16
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2021-08-13
F · Potential for more than minimal harm
2021-06-16
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2021-08-13
F · Potential for more than minimal harm
2021-06-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-08-13
F · Potential for more than minimal harm
2021-06-16
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-08-13
F · Potential for more than minimal harm
2021-06-16
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 2021-08-13
F · Potential for more than minimal harm
2021-06-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-08-13
E · Potential for more than minimal harm
2021-06-16
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2021-08-13
E · Potential for more than minimal harm
2021-06-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-08-13
D · Potential for more than minimal harm
2021-06-16
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-08-13
Inspection history
Recent health citations
G · Actual harm
2024-07-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-08-01
F · Potential for more than minimal harm
2024-07-10
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2024-08-01
F · Potential for more than minimal harm
2024-07-10
F942 · Resident Rights Deficiencies
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2024-08-01
F · Potential for more than minimal harm
2024-07-10
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-08-01
E · Potential for more than minimal harm
2024-07-10
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 2024-08-01
E · Potential for more than minimal harm
2024-07-10
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 2024-08-01
E · Potential for more than minimal harm
2024-07-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-07-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-07-10
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 2024-08-01
D · Potential for more than minimal harm
2024-07-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-07-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-07-10
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 2024-08-01
D · Potential for more than minimal harm
2024-07-10
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 2024-08-01
D · Potential for more than minimal harm
2024-07-10
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-07-10
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 2024-08-01
D · Potential for more than minimal harm
2024-07-10
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 2024-08-01
D · Potential for more than minimal harm
2024-07-10
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-08-01
C · Minimal harm
2024-07-10
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-08-01
G · Actual harm
2024-03-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-23
D · Potential for more than minimal harm
2023-03-20
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 2023-04-07
D · Potential for more than minimal harm
2023-03-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-04-07
E · Potential for more than minimal harm
2022-11-02
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 2022-12-01
E · Potential for more than minimal harm
2022-11-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-01
D · Potential for more than minimal harm
2022-11-02
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 2022-12-01
D · Potential for more than minimal harm
2022-11-02
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 2022-12-01
D · Potential for more than minimal harm
2022-11-02
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 2022-12-01
D · Potential for more than minimal harm
2022-11-02
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 2022-12-01
D · Potential for more than minimal harm
2022-11-02
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-12-01
D · Potential for more than minimal harm
2022-11-02
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-12-01
D · Potential for more than minimal harm
2022-11-02
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 2022-12-01
D · Potential for more than minimal harm
2022-11-02
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 2022-12-01
G · Actual harm
2021-06-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-07-02
E · Potential for more than minimal harm
2021-06-16
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 2021-07-02
E · Potential for more than minimal harm
2021-06-16
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 2021-07-02
E · Potential for more than minimal harm
2021-06-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-07-02
D · Potential for more than minimal harm
2021-06-16
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 2021-07-02
D · Potential for more than minimal harm
2021-06-16
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 2021-07-02
D · Potential for more than minimal harm
2021-06-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-07-02
D · Potential for more than minimal harm
2021-06-16
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 2021-07-02
D · Potential for more than minimal harm
2021-06-16
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 2021-07-02
D · Potential for more than minimal harm
2021-06-16
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 2021-07-02
D · Potential for more than minimal harm
2021-06-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-07-02
D · Potential for more than minimal harm
2021-06-16
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-07-02
D · Potential for more than minimal harm
2021-06-16
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-07-02
D · Potential for more than minimal harm
2021-06-16
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 2021-07-02
Penalties and ownership
What sits behind the stars
$28,834
2024-07-10
Fine
Fine · fine $28,834
Fine
Ownership
Gateway Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Fitch, Craig
Corporate Officer · Individual
Leiker, Ryan
Operational/Managerial Control · Individual
Leiker, Ryan
W-2 Managing Employee · Individual
Lewis, Corwin
Corporate Officer · Individual
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