6 health deficiencies
Top issue: Infection Control (2 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Wathena, KS
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
2112 Highway 36, Wathena, KS
(785) 989-3141
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
Beds
60
Certified beds
Average residents
39
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Recover-Care Healthcare
Operator or chain grouping
Approved since
1992-01-31
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.66
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.67
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.25
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.57
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.16
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.63
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
0.62
CMS adjusted RN staffing hours
Adjusted total hours
3.36
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
10,117
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.39
Composite VBP score used to determine payment impact.
Payment multiplier
0.9826
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
2.6
Baseline 23.93% · Performance 21.79% · Measure score 2.6 · Achievement 0 · Improvement 2.6
Healthcare-associated infections
2.43
Baseline 10.38% · Performance 8.81% · Measure score 2.43 · Achievement 0 · Improvement 2.43
Total nurse turnover
2.74
Baseline 51.22% · Performance 52.50% · Measure score 2.74 · Achievement 2.74 · Improvement 0
Adjusted total nurse staffing
0.79
Baseline 3.36 hours · Performance 3.30 hours · Measure score 0.79 · Achievement 0.79 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.91% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 79 · Observed rate 13.92% · Lower 95% interval 7.72% |
| Discharge to community | 47.22% |
50.57%
3.4 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 40.74% · Lower 95% interval 37.45% |
| Medicare spending per beneficiary | 1.3 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 48 · Denominator 48 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 48 |
| Discharge self-care score | 39.39% |
53.69%
14.3 pts worse
|
Numerator 13 · Denominator 33 |
| Discharge mobility score | 57.58% |
50.94%
6.6 pts better
|
Numerator 19 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 4.17% |
2.29%
1.9 pts worse
|
Numerator 2 · Denominator 48 · Adjusted rate 3.52% |
| Healthcare-associated infections requiring hospitalization | 8.81% |
7.12%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 14% · Lower 95% interval 4.77% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 42 |
| Staff flu vaccination coverage | 10.29% |
42%
31.7 pts worse
|
Numerator 7 · Denominator 68 |
| Discharge function score | 48.48% |
56.45%
8 pts worse
|
Numerator 16 · Denominator 33 |
| Transfer of health information to provider | 95.83% |
95.95%
0.1 pts worse
|
Numerator 23 · Denominator 24 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 25% |
25.2%
0.2 pts worse
|
Numerator 6 · Denominator 24 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
1.8
1 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.9 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.2
0.9 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.5 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.4% |
91.8%
3.4 pts worse
|
93.4%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 91.2% · Q2 88.2% · Q3 85.7% · Q4 88.6% · 4Q avg 88.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.3% |
95.5%
1.2 pts worse
|
95.5%
1.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.7% |
4.4%
3.7 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.6%
5.6 pts better
|
11.4%
11.4 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 who lose too much weight | 8.0% |
5.0%
3 pts worse
|
5.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 11.5% · Q3 13.8% · Q4 6.7% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.1% |
23.2%
14.1 pts better
|
19.6%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 10.0% · Q3 6.7% · Q4 12.9% · 4Q avg 9.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.9% |
19.8%
1.9 pts better
|
16.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 20.0% · Q3 17.4% · Q4 13.6% · 4Q avg 17.9% · 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 | 8.9% |
18.4%
9.5 pts better
|
16.3%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.5% |
18.8%
3.7 pts worse
|
14.9%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 10.0% · Q3 26.7% · Q4 29.0% · 4Q avg 22.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.8% |
1.8%
1 pts worse
|
1.0%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q3 0.0% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.1% |
3.1%
About the same
|
1.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 3.3% · Q3 0.0% · Q4 0.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 36.8% |
23.2%
13.6 pts worse
|
19.8%
17 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.5% · Q3 28.1% · Q4 35.1% · 4Q avg 36.8% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
4.6%
1.3 pts worse
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 3.4% · Q3 3.0% · Q4 8.8% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 38.1% |
75.6%
37.5 pts worse
|
81.7%
43.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 50.0% · Q2 45.0% · Q3 34.2% · Q4 21.6% · 4Q avg 38.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.5% |
11.7%
2.2 pts better
|
12.0%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.5% · Observed 8.6% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 36.8% |
73.5%
36.7 pts worse
|
79.7%
42.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 36.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.8% |
23.0%
6.2 pts better
|
23.9%
7.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.8% · Observed 14.3% · Expected 20.3% · Used in QM five-star |
Survey summary
Top issue: Infection Control (2 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Top issue: Pharmacy Service (3 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Fire safety
Fire Safety
Use approved construction type or materials.
Corrected 2024-11-18
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-12-11
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-16
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-11
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-11
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-11
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-12-11
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-12-11
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-11
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-11
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2023-06-20
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-06-20
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-06-20
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-20
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-20
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-06-20
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2021-12-01
Fire Safety
Establish staff and initial training requirements.
Corrected 2021-12-01
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2021-12-01
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2021-12-01
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-12-01
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-12-01
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-12-01
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-12-01
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-12-01
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-12-01
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 2021-12-01
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-12-01
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-12-01
Inspection history
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 2024-11-01
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-01
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 2024-11-01
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-01
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2024-11-01
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-11-01
Health
Provide activities to meet all resident's needs.
Corrected 2023-06-04
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 2023-06-04
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-06-04
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-06-04
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-06-04
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 2023-06-04
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-04
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-04
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 2023-06-04
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-06-04
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-04
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-06-04
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2023-06-04
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-11-23
Health
Provide and implement an infection prevention and control program.
Corrected 2021-11-23
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2021-11-23
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-11-23
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-11-23
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 2021-11-23
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-11-23
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
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