Cycle 1
Health 2024-03-20 · Fire 2024-03-20
19 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
22 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Tonganoxie, KS
Tonganoxie Terrace
2-star overall rating with 2-star inspections with $13,397 in total fines with 19 recent health deficiencies with 22 fire-safety deficiencies in the latest cycle
1010 East Street, Tonganoxie, KS
(913) 369-8705
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
70
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1992-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.75
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.42
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.55
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.72
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.17
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.18
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
3.52
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,894
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
9.79
Composite VBP score used to determine payment impact.
Payment multiplier
0.9808
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.32
Baseline 21.92% · Performance 21.52% · Measure score 0.32 · Achievement 0 · Improvement 0.32
Healthcare-associated infections
0
Baseline 7.38% · Performance 8.20% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.61
Baseline 67.57% · Performance 54.29% · Measure score 2.61 · Achievement 2.30 · Improvement 2.61
Adjusted total nurse staffing
0.99
Baseline 3.48 hours · Performance 3.36 hours · Measure score 0.99 · Achievement 0.99 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.01% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 97 · Observed rate 15.46% · Lower 95% interval 8.3% |
| Discharge to community | 42.37% |
50.57%
8.2 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 36% · Lower 95% interval 32.26% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 94.52% |
95.27%
0.8 pts worse
|
Numerator 69 · Denominator 73 |
| Falls with major injury | 1.37% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 73 |
| Discharge self-care score | 44.44% |
53.69%
9.2 pts worse
|
Numerator 20 · Denominator 45 |
| Discharge mobility score | 31.11% |
50.94%
19.8 pts worse
|
Numerator 14 · Denominator 45 |
| Pressure ulcers or injuries, new or worsened | 2.74% |
2.29%
0.5 pts worse
|
Numerator 2 · Denominator 73 · Adjusted rate 2.23% |
| Healthcare-associated infections requiring hospitalization | 8.2% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 53 · Observed rate 13.21% · Lower 95% interval 4.81% |
| Staff COVID-19 vaccination coverage | 95.65% |
8.2%
87.5 pts better
|
Numerator 88 · Denominator 92 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 37.78% |
56.45%
18.7 pts worse
|
Numerator 17 · Denominator 45 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 57.5% |
25.2%
32.3 pts better
|
Numerator 23 · Denominator 40 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
1.8
0.9 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 3.3 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
2.2
0.6 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.7 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.8% |
91.8%
3 pts better
|
93.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 100.0% · Q3 88.9% · Q4 90.8% · 4Q avg 94.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.3% |
95.5%
0.2 pts worse
|
95.5%
0.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
4.4%
2.3 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.6% · Q3 2.8% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.5% |
5.6%
6.9 pts worse
|
11.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 11.3% · Q3 23.8% · Q4 16.7% · 4Q avg 12.5% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
5.0%
0.3 pts worse
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.7% · Q3 11.1% · Q4 8.2% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.1% |
23.2%
4.1 pts better
|
19.6%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 20.0% · Q3 20.7% · Q4 14.8% · 4Q avg 19.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.9% |
19.8%
14.9 pts better
|
16.7%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 4.7% · Q3 2.2% · Q4 4.5% · 4Q avg 4.9% · 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 | 21.9% |
18.4%
3.5 pts worse
|
16.3%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.3% · Q4 5.5% · 4Q avg 21.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.3% |
18.8%
5.5 pts better
|
14.9%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 14.5% · Q3 10.5% · Q4 9.3% · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.0% |
1.8%
2.2 pts worse
|
1.0%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 5.6% · Q3 2.1% · Q4 3.3% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.6% |
3.1%
0.5 pts worse
|
1.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 8.8% · Q4 5.0% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.6% |
23.2%
6.6 pts better
|
19.8%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 26.1% · Q3 8.7% · Q4 17.4% · 4Q avg 16.6% |
| 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 7.5% · Q2 4.7% · Q3 3.1% · Q4 4.7% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 63.7% |
75.6%
11.9 pts worse
|
81.7%
18 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.1% · Q3 52.5% · Q4 26.8% · 4Q avg 63.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.1% |
11.7%
3.6 pts better
|
12.0%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.1% · Observed 9.0% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 7.0% |
2.2%
4.8 pts worse
|
1.6%
5.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q4 12.0% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.4% |
73.5%
8.9 pts better
|
79.7%
2.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.5% |
23.0%
8.5 pts worse
|
23.9%
7.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.5% · Observed 32.8% · Expected 24.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-07 · Fire 2022-09-07
21 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
21 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2021-03-11 · Fire 2021-03-11
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-03-20
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-05-30
F · Potential for more than minimal harm
2024-03-20
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-05-30
F · Potential for more than minimal harm
2024-03-20
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-05-30
F · Potential for more than minimal harm
2024-03-20
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-05-30
F · Potential for more than minimal harm
2024-03-20
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-06-21
F · Potential for more than minimal harm
2024-03-20
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-05-30
F · Potential for more than minimal harm
2024-03-20
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-05-30
F · Potential for more than minimal harm
2024-03-20
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-05-30
F · Potential for more than minimal harm
2024-03-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-05-30
F · Potential for more than minimal harm
2024-03-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-21
F · Potential for more than minimal harm
2024-03-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-30
F · Potential for more than minimal harm
2024-03-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-30
F · Potential for more than minimal harm
2024-03-20
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 2024-05-30
F · Potential for more than minimal harm
2024-03-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-21
F · Potential for more than minimal harm
2024-03-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-30
E · Potential for more than minimal harm
2024-03-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-30
E · Potential for more than minimal harm
2024-03-20
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2024-05-30
E · Potential for more than minimal harm
2024-03-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-30
E · Potential for more than minimal harm
2024-03-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-21
E · Potential for more than minimal harm
2024-03-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-03-20
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 2024-05-30
D · Potential for more than minimal harm
2024-03-20
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-05-30
F · Potential for more than minimal harm
2022-09-07
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2022-10-13
F · Potential for more than minimal harm
2022-09-07
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-10-13
F · Potential for more than minimal harm
2022-09-07
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-10-13
F · Potential for more than minimal harm
2022-09-07
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-10-13
F · Potential for more than minimal harm
2022-09-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-10-13
F · Potential for more than minimal harm
2022-09-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-13
F · Potential for more than minimal harm
2022-09-07
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-10-13
F · Potential for more than minimal harm
2022-09-07
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-10-13
F · Potential for more than minimal harm
2022-09-07
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-10-13
F · Potential for more than minimal harm
2022-09-07
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-10-13
F · Potential for more than minimal harm
2022-09-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-10-13
F · Potential for more than minimal harm
2022-09-07
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-10-13
F · Potential for more than minimal harm
2022-09-07
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2022-10-13
F · Potential for more than minimal harm
2022-09-07
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 2022-10-13
F · Potential for more than minimal harm
2022-09-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-13
F · Potential for more than minimal harm
2022-09-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-10-13
E · Potential for more than minimal harm
2022-09-07
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-10-13
E · Potential for more than minimal harm
2022-09-07
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-10-13
E · Potential for more than minimal harm
2022-09-07
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 2022-10-13
E · Potential for more than minimal harm
2022-09-07
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-10-13
E · Potential for more than minimal harm
2022-09-07
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2022-10-13
F · Potential for more than minimal harm
2021-03-11
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2020-03-31
F · Potential for more than minimal harm
2021-03-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-03-31
F · Potential for more than minimal harm
2021-03-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-03-31
F · Potential for more than minimal harm
2021-03-11
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2020-03-31
F · Potential for more than minimal harm
2021-03-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2020-03-31
F · Potential for more than minimal harm
2021-03-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-03-31
F · Potential for more than minimal harm
2021-03-11
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 2020-03-31
F · Potential for more than minimal harm
2021-03-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-03-31
F · Potential for more than minimal harm
2021-03-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-03-31
E · Potential for more than minimal harm
2021-03-11
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2020-03-31
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-06
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-09-02
D · Potential for more than minimal harm
2025-08-06
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-02
D · Potential for more than minimal harm
2025-08-06
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-09-02
F · Potential for more than minimal harm
2024-03-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-03
F · Potential for more than minimal harm
2024-03-20
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 2024-05-03
E · Potential for more than minimal harm
2024-03-20
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 2024-05-03
E · Potential for more than minimal harm
2024-03-20
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 2024-05-03
E · Potential for more than minimal harm
2024-03-20
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 2024-05-03
D · Potential for more than minimal harm
2024-03-20
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-03-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-03-20
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 2024-05-03
D · Potential for more than minimal harm
2024-03-20
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 2024-05-03
D · Potential for more than minimal harm
2024-03-20
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 2024-05-03
D · Potential for more than minimal harm
2024-03-20
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 2024-05-03
D · Potential for more than minimal harm
2024-03-20
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-03-20
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 2024-05-03
D · Potential for more than minimal harm
2024-03-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-03-20
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 2024-05-03
D · Potential for more than minimal harm
2024-03-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-05-03
J · Immediate jeopardy
2023-08-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-16
D · Potential for more than minimal harm
2023-05-08
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 2023-06-10
F · Potential for more than minimal harm
2022-09-07
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 2022-10-21
F · Potential for more than minimal harm
2022-09-07
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2022-10-21
F · Potential for more than minimal harm
2022-09-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-21
F · Potential for more than minimal harm
2022-09-07
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2022-10-21
E · Potential for more than minimal harm
2022-09-07
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 2022-10-21
E · Potential for more than minimal harm
2022-09-07
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 2022-10-21
E · Potential for more than minimal harm
2022-09-07
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 2022-10-21
E · Potential for more than minimal harm
2022-09-07
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-10-21
E · Potential for more than minimal harm
2022-09-07
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2022-10-21
D · Potential for more than minimal harm
2022-09-07
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-10-21
D · Potential for more than minimal harm
2022-09-07
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 2022-10-21
D · Potential for more than minimal harm
2022-09-07
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-10-21
D · Potential for more than minimal harm
2022-09-07
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 2022-10-21
D · Potential for more than minimal harm
2022-09-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-21
D · Potential for more than minimal harm
2022-09-07
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 2022-10-21
D · Potential for more than minimal harm
2022-09-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-10-21
D · Potential for more than minimal harm
2022-09-07
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-10-21
D · Potential for more than minimal harm
2022-09-07
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 2022-10-21
D · Potential for more than minimal harm
2022-09-07
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 2022-10-21
D · Potential for more than minimal harm
2022-09-07
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-10-21
D · Potential for more than minimal harm
2022-09-07
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 2022-10-21
J · Immediate jeopardy
2021-03-11
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-03-26
F · Potential for more than minimal harm
2021-03-11
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2021-03-26
D · Potential for more than minimal harm
2021-03-11
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2021-03-26
D · Potential for more than minimal harm
2021-03-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-03-26
D · Potential for more than minimal harm
2021-03-11
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 2021-03-26
Penalties and ownership
What sits behind the stars
$13,397
2023-08-31
Fine
Fine · fine $13,397
Fine
Ownership
Navas-Migueloa, Luis
5% Or Greater Direct Ownership Interest · Individual
Goldberg, Nathan
5% Or Greater Direct Ownership Interest · Individual
Insel, David
5% Or Greater Direct Ownership Interest · Individual
Marcotte, Richard
W-2 Managing Employee · Individual
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