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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G3 | H· | I· |
| Potential harm | D51 | E18 | F28 |
| Minimal | A· | B· | C2 |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| Jul 14, 2026 | Health | Health Complaint | 4 | Potential harm | — | Open → |
| May 26, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Feb 24, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Feb 2, 2026 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Apr 23, 2025 | Health | Health Complaint | 1 | Actual harm | — | Open → |
| Sep 11, 2024 | Fire safety | Fire Safety Standard | 14 | Potential harm | — | Open → |
| Sep 11, 2024 | Health | Health Complaint, Health Standard | 22 | Potential harm | — | Open → |
| Jul 3, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Feb 28, 2024 | Health | Health Complaint | 2 | Actual harm | — | Open → |
| Dec 5, 2022 | Fire safety | Fire Safety Standard | 15 | Potential harm | — | Open → |
| Dec 5, 2022 | Health | Health Standard | 16 | Actual harm | — | Open → |
| May 3, 2021 | Fire safety | Fire Safety Standard | 10 | Potential harm | — | Open → |
| May 3, 2021 | Health | Health Standard | 12 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Apr 23, 2025 | Denial of payment for new admissions | — | May 20, 2025 · 10 days | 175180|Payment Denial|2025-05-20 |
| Apr 23, 2025 | Civil money penalty (fine) | $22,505 | — | 175180|Fine|134961 |
| Feb 28, 2024 | Civil money penalty (fine) | $37,557 | — | 175180|Fine|82373 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G3 | H· | I· |
| Potential harm | D51 | E18 | F28 |
| Minimal | A· | B· | C2 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Jul 14, 2026 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 3, 2026 | Complaint |
| Jul 14, 2026 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 3, 2026 | Complaint |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
CMS legal business name of the certified provider. Operates this facility only.
277 facilities in 16 states. CMS chain ID 690.
Chain average overall rating (CMS): 3
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Frederick Apt | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | May 20, 2024 |
| Mark Hancock | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Sep 3, 2025 |
| Joshua Jergensen | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | May 20, 2024 |
| John Mitchell | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | May 20, 2024 |
| Frederick Apt | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | May 20, 2024 |
| Mark Hancock | Individual |
| Facility | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|
| Great Plains Post Acute 7101 E 21st Street North, Wichita, KS 67206 CCN 175168 | 118 | Jun 15, 2026 | 873 IJ6 harm | $42k |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Advanced Health Care of Overland Park 4700 Indian Creek Parkway, Overland Park, KS 66207 CCN 175542 | 0.8 km | 38 | Aug 19, 2026 | 661 IJ1 open | $13k | |
| Swan Health at Overland Park 6505 W 103rd Street, Overland Park, KS 66212 CCN 175240 | 1.2 km | 44 | Aug 24, 2026 | 792 IJ2 harm | $93k | |
| Brookdale Overland Park 12000 Lamar Avenue, Overland Park, KS 66209 CCN 175517 | 3.6 km | 94 | Apr 14, 2026 | 37 | — | |
| Ignite Medical Resort Carondelet LLC 621 Carondelet Drive, Kansas City, MO 64114 CCN 265303 | 3.9 km | 162 | Jun 25, 2026 | 1221 harm1 open | — | |
| Village Shalom Inc 5500 West 123rd St, Overland Park, KS 66209 CCN 175441 | 4 km | 66 | Jun 4, 2025 | 662 harm | $16k | |
| Kingswood Senior Living 10000 Wornall Road, Kansas City, MO 64114 CCN 265795 | 4.4 km | 86 | Jul 23, 2026 | 712 IJ | $135k | |
| Claridge Court 8101 Mission Road, Prairie Village, KS 66208 CCN 175343 | 4.7 km | 45 | Jan 14, 2026 | 472 IJ1 harm | $18k | |
| Ignite Medical Resort Overland Park LLC 11901 Rosewood Street, Overland Park, KS 66209 CCN 175183 | 5.7 km | 102 | Jul 29, 2026 | 812 harm15 open | $6,942 |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 175180 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 175180 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| Jul 14, 2026 | F-0726 | 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. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Aug 3, 2026 | Complaint |
| Jul 14, 2026 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Aug 3, 2026 | Complaint |
| May 26, 2026 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jun 4, 2026 | Complaint |
| Feb 24, 2026 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 13, 2026 | Complaint |
| Feb 2, 2026 | F-0687 | Provide appropriate foot care. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 3, 2026 | Complaint |
| Feb 2, 2026 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 3, 2026 | Complaint |
| Feb 2, 2026 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Mar 3, 2026 | Complaint |
| Apr 23, 2025 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected May 30, 2025 | Complaint |
| Sep 11, 2024 | E-0009 | Include a process for Emergency Preparedness collaboration. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Nov 25, 2024 |
| Sep 11, 2024 | E-0024 | Establish policies and procedures for volunteers. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Nov 25, 2024 |
| Sep 11, 2024 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 19, 2024 |
| Sep 11, 2024 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 19, 2024 |
| Sep 11, 2024 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 25, 2024 |
| Sep 11, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 19, 2024 |
| Sep 11, 2024 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 19, 2024 |
| Sep 11, 2024 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 19, 2024 |
| Sep 11, 2024 | K-0531 | Have elevators that firefighters can control in the event of a fire. Services Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 25, 2024 |
| Sep 11, 2024 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 25, 2024 |
| Sep 11, 2024 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 19, 2024 |
| Sep 11, 2024 | K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 19, 2024 |
| Sep 11, 2024 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 19, 2024 |
| Sep 11, 2024 | K-0920 | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 19, 2024 |
| Sep 11, 2024 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Oct 11, 2024 | Complaint |
| Sep 11, 2024 | F-0582 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Oct 11, 2024 | Complaint |
| Sep 11, 2024 | F-0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Oct 11, 2024 | Complaint |
| Sep 11, 2024 | F-0638 | Assure that each resident’s assessment is updated at least once every 3 months. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 11, 2024 | Complaint |
| Sep 11, 2024 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 11, 2024 | Complaint |
| Sep 11, 2024 | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Oct 11, 2024 | Complaint |
| Sep 11, 2024 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 11, 2024 | Complaint |
| Sep 11, 2024 | F-0688 | 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. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 11, 2024 | Complaint |
| Sep 11, 2024 | F-0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 11, 2024 | Complaint |
| Sep 11, 2024 | F-0700 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 11, 2024 | Complaint |
| Sep 11, 2024 | F-0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Oct 11, 2024 | Complaint |
| Sep 11, 2024 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Oct 11, 2024 | Complaint |
| Sep 11, 2024 | F-0758 | 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. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Oct 11, 2024 | Complaint |
| Sep 11, 2024 | F-0801 | 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. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Oct 11, 2024 | Complaint |
| Sep 11, 2024 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Oct 11, 2024 | Complaint |
| Sep 11, 2024 | F-0838 | 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. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Oct 11, 2024 | Complaint |
| Sep 11, 2024 | F-0849 | 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. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Oct 11, 2024 | Complaint |
| Sep 11, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Oct 11, 2024 | Complaint |
| Sep 11, 2024 | F-0941 | Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Oct 11, 2024 | Complaint |
| Sep 11, 2024 | F-0942 | Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Oct 11, 2024 | Complaint |
| Sep 11, 2024 | F-0945 | Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Oct 11, 2024 | Complaint |
| Sep 11, 2024 | F-0576 | Ensure residents have reasonable access to and privacy in their use of communication methods. Resident Rights Deficiencies · Resident rights & abuse/neglect | C · Minimal Widespread | Corrected Oct 11, 2024 | Complaint |
| Jul 3, 2024 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 6, 2024 | Complaint |
| Feb 28, 2024 | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Mar 26, 2024 | Complaint |
| Feb 28, 2024 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 26, 2024 | Complaint |
| Dec 5, 2022 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Jan 7, 2023 |
| Dec 5, 2022 | K-0161 | Use approved construction type or materials. Construction Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 17, 2023 |
| Dec 5, 2022 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Feb 17, 2023 |
| Dec 5, 2022 | K-0222 | 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. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 17, 2023 |
| Dec 5, 2022 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Feb 17, 2023 |
| Dec 5, 2022 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Feb 17, 2023 |
| Dec 5, 2022 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 17, 2023 |
| Dec 5, 2022 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 17, 2023 |
| Dec 5, 2022 | K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Feb 17, 2023 |
| Dec 5, 2022 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Feb 17, 2023 |
| Dec 5, 2022 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 17, 2023 |
| Dec 5, 2022 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 17, 2023 |
| Dec 5, 2022 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 17, 2023 |
| Dec 5, 2022 | K-0753 | Have restrictions on the use of highly flammable decorations. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 17, 2023 |
| Dec 5, 2022 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 17, 2023 |
| Dec 5, 2022 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 17, 2023 |
| Dec 5, 2022 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 7, 2023 |
| Dec 5, 2022 | F-0602 | Protect each resident from the wrongful use of the resident's belongings or money. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 7, 2023 |
| Dec 5, 2022 | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 7, 2023 |
| Dec 5, 2022 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 7, 2023 |
| Dec 5, 2022 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 7, 2023 |
| Dec 5, 2022 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jan 7, 2023 |
| Dec 5, 2022 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 7, 2023 |
| Dec 5, 2022 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 7, 2023 |
| Dec 5, 2022 | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 7, 2023 |
| Dec 5, 2022 | F-0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 7, 2023 |
| Dec 5, 2022 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Jan 7, 2023 |
| Dec 5, 2022 | F-0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jan 7, 2023 |
| Dec 5, 2022 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jan 7, 2023 |
| Dec 5, 2022 | F-0761 | 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. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Jan 7, 2023 |
| Dec 5, 2022 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jan 7, 2023 |
| May 3, 2021 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 14, 2021 |
| May 3, 2021 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 14, 2021 |
| May 3, 2021 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 14, 2021 |
| May 3, 2021 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 14, 2021 |
| May 3, 2021 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 14, 2021 |
| May 3, 2021 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 14, 2021 |
| May 3, 2021 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 14, 2021 |
| May 3, 2021 | K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 14, 2021 |
| May 3, 2021 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 14, 2021 |
| May 3, 2021 | K-0920 | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 14, 2021 |
| May 3, 2021 | F-0582 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 9, 2021 |
| May 3, 2021 | F-0661 | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 9, 2021 |
| May 3, 2021 | F-0676 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jun 9, 2021 |
| May 3, 2021 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 9, 2021 |
| May 3, 2021 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 9, 2021 |
| May 3, 2021 | F-0740 | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 9, 2021 |
| May 3, 2021 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jun 9, 2021 |
| May 3, 2021 | F-0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Past non-compliance May 3, 2021 |
| May 3, 2021 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jun 9, 2021 |
| May 3, 2021 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jun 9, 2021 |
| May 3, 2021 | F-0801 | 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. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | C · Minimal Widespread | Corrected Jun 9, 2021 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 2.96 (case-mix index 1.21).
| Operational / managerial control |
| OPERATIONAL/MANAGERIAL CONTROL |
| not provided |
| Sep 3, 2025 |
| Joshua Jergensen | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | May 20, 2024 |
| Bobbi Kramer | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jan 1, 2025 |
| Tamara Mccue | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jul 15, 2024 |
| John Mitchell | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | May 20, 2024 |
| John Remick | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Feb 1, 2025 |
| Leisure Terrace Land LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | May 1, 2017 |
| Providence Administrative Consulting Services Inc | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jul 15, 2024 |
| Tamara Mccue | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Dec 2, 2025 |
| John Remick | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Dec 2, 2025 |