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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J3 | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D40 | E18 | F51 |
| 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 | |
|---|---|---|---|---|---|---|
| Apr 29, 2026 | Fire safety | Fire Safety Standard | 12 | Potential harm | — | Open → |
| Apr 29, 2026 | Health | Health Complaint, Health Standard | 14 | Potential harm | — | Open → |
| Feb 2, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Aug 5, 2024 | Fire safety | Fire Safety Standard | 21 | Potential harm | — | Open → |
| Aug 5, 2024 | Health | Health Complaint, Health Standard | 20 | Immediate jeopardy | — | Open → |
| Dec 13, 2022 | Fire safety | Fire Safety Standard | 21 | Potential harm | — | Open → |
| Dec 13, 2022 | Health | Health Standard | 26 | Actual harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Aug 5, 2024 | Civil money penalty (fine) | $16,801 | — | 175274|Fine|82414 |
| Aug 5, 2024 | Civil money penalty (fine) | $16,055 | — | 175274|Fine|82412 |
| Aug 5, 2024 | Civil money penalty (fine) | $13,627 | — | 175274|Fine|82413 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J3 | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D40 | E18 | F51 |
| Minimal | A· | B· | C2 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Apr 29, 2026 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 4, 2026 | |
| Apr 29, 2026 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jul 4, 2026 | |
| Apr 29, 2026 | K-0321 |
“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.
24 facilities in 5 states. CMS chain ID 531.
Chain average overall rating (CMS): 2.3
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Jct Family Limited Partnership | Organization | Partner | LIMITED PARTNERSHIP INTEREST | not provided | Jan 1, 2005 |
| Dominic Tutera | Individual | Partner | LIMITED PARTNERSHIP INTEREST | not provided | Jan 1, 2005 |
| Hannah Tutera | Individual | Partner | LIMITED PARTNERSHIP INTEREST | not provided | Jan 1, 2005 |
| Joseph Tutera | Individual | Partner | LIMITED PARTNERSHIP INTEREST | not provided | Jan 1, 2005 |
| Laura Tutera | Individual | Partner | LIMITED PARTNERSHIP INTEREST | not provided | Jan 1, 2005 |
| Walnut Creek Management Company LLC |
| Facility | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|
| Westview of Derby Rehabilitation & Health Care Cen 445 N Westview Dr, Derby, KS 67037 CCN 175218 | 78 | Sep 16, 2025 | 1073 IJ1 harm | $74k | |
| The Village at Mission 7105 Mission Road, Prairie Village, KS 66208 CCN 175499 |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Ascension Living Via Christi Village Mclean 777 N Mclean Blvd, Wichita, KS 67203 CCN 175543 | 1.5 km | 36 | Aug 14, 2025 | 201 harm | — | |
| Lakepoint Wichita, LLC 1315 N West Street, Wichita, KS 67203 CCN 175466 | 1.7 km | 110 | Dec 4, 2024 | 742 harm | — | |
| Wichita Presbyterian Manor 4700 W 13th Street North, Wichita, KS 67212 CCN 175301 | 2.3 km | 50 | May 28, 2025 | 401 IJ | — | |
| Sandpiper Healthcare & Rehabilitation Center 5808 W 8th Street North, Wichita, KS 67212 CCN 175344 | 3.7 km | 104 | Nov 7, 2024 | 833 IJ | $17k | |
| Homestead Health Center 2133 S Elizabeth Street, Wichita, KS 67213 CCN 175487 | 6.3 km | 45 | May 14, 2026 | 502 IJ1 harm | $60k | |
| Via Christi Village Ridge 3636 North Ridge Rd Bldg 400, Wichita, KS 67205 CCN 175539Abuse icon | 6.4 km | 80 | Feb 11, 2026 | 702 harm | $23k | |
| Azria Health Wichita 7057 West Village Circle, Wichita, KS 67205 CCN 175563 | 7.1 km | 70 | Feb 25, 2026 | 731 harm | — | |
| Mount St Mary 3700 E Lincoln St, Wichita, KS 67218 CCN 175561 | 8.1 km | 24 | Mar 31, 2025 | 32 | — |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 175274 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 175274 | 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
| 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 Jul 4, 2026 |
| Apr 29, 2026 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jul 4, 2026 |
| Apr 29, 2026 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 4, 2026 |
| Apr 29, 2026 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jul 4, 2026 |
| Apr 29, 2026 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 4, 2026 |
| Apr 29, 2026 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jul 4, 2026 |
| Apr 29, 2026 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 4, 2026 |
| Apr 29, 2026 | 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 Jul 4, 2026 |
| Apr 29, 2026 | 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 Jul 4, 2026 |
| Apr 29, 2026 | 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 Jul 4, 2026 |
| Apr 29, 2026 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 5, 2026 |
| Apr 29, 2026 | F-0553 | Allow resident to participate in the development and implementation of his or her person-centered plan of care. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 5, 2026 |
| Apr 29, 2026 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 5, 2026 |
| Apr 29, 2026 | F-0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 5, 2026 |
| Apr 29, 2026 | F-0636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jun 5, 2026 |
| Apr 29, 2026 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 5, 2026 |
| Apr 29, 2026 | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 5, 2026 |
| Apr 29, 2026 | 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 5, 2026 |
| Apr 29, 2026 | 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 Jun 5, 2026 | Complaint |
| Apr 29, 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 Jun 5, 2026 |
| Apr 29, 2026 | 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 5, 2026 |
| Apr 29, 2026 | 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 Jun 5, 2026 |
| Apr 29, 2026 | F-0814 | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | C · Minimal Widespread | Corrected Jun 5, 2026 |
| Apr 29, 2026 | F-0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Jun 5, 2026 |
| Feb 2, 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 | E · Potential harm Pattern | Corrected Feb 23, 2026 | Complaint |
| Aug 5, 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 | J · Immediate jeopardy Isolated | Past non-compliance Jul 23, 2024 | Complaint |
| Aug 5, 2024 | 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 | J · Immediate jeopardy Isolated | Past non-compliance Jul 2, 2024 | Complaint |
| Aug 5, 2024 | F-0742 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. Quality of Life and Care Deficiencies · Clinical care | J · Immediate jeopardy Isolated | Past non-compliance Jul 23, 2024 | Complaint |
| Aug 5, 2024 | E-0007 | Address patient/client population and determine types of services needed. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Aug 5, 2024 | E-0023 | Establish policies and procedures for medical documentation. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Aug 5, 2024 | E-0024 | Establish policies and procedures for volunteers. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Aug 5, 2024 | K-0100 | Meet other general requirements. Construction Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Aug 5, 2024 | 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 | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Aug 5, 2024 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Aug 5, 2024 | 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 | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Aug 5, 2024 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Aug 5, 2024 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Aug 5, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Aug 5, 2024 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Aug 5, 2024 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Aug 5, 2024 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Aug 5, 2024 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Aug 5, 2024 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Aug 5, 2024 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Aug 5, 2024 | 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 | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Aug 5, 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 Sep 30, 2024 |
| Aug 5, 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 Sep 30, 2024 |
| Aug 5, 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 Sep 30, 2024 |
| Aug 5, 2024 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Aug 5, 2024 | F-0553 | Allow resident to participate in the development and implementation of his or her person-centered plan of care. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 3, 2024 | Complaint |
| Aug 5, 2024 | F-0557 | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 3, 2024 | Complaint |
| Aug 5, 2024 | F-0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Sep 3, 2024 |
| Aug 5, 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 Sep 3, 2024 |
| Aug 5, 2024 | F-0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Sep 3, 2024 |
| Aug 5, 2024 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Sep 3, 2024 |
| Aug 5, 2024 | 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 | E · Potential harm Pattern | Corrected Sep 3, 2024 |
| Aug 5, 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 | E · Potential harm Pattern | Corrected Sep 3, 2024 |
| Aug 5, 2024 | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 3, 2024 |
| Aug 5, 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 Sep 3, 2024 |
| Aug 5, 2024 | F-0730 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Sep 3, 2024 |
| Aug 5, 2024 | 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 Sep 3, 2024 | Complaint |
| Aug 5, 2024 | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Sep 3, 2024 |
| Aug 5, 2024 | F-0806 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Sep 3, 2024 |
| Aug 5, 2024 | F-0923 | Have enough outside ventilation via a window or mechanical ventilation, or both. Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Sep 3, 2024 |
| Aug 5, 2024 | F-0947 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Sep 3, 2024 |
| Aug 5, 2024 | F-0949 | Provide behavior health training consistent with the requirements and as determined by a facility assessment. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Sep 3, 2024 |
| Dec 13, 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 | G · Actual harm Isolated | Corrected Feb 22, 2023 |
| Dec 13, 2022 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 7, 2023 |
| Dec 13, 2022 | E-0007 | Address patient/client population and determine types of services needed. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 7, 2023 |
| Dec 13, 2022 | E-0018 | Establish procedures for tracking staff and patients during an emergency. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 7, 2023 |
| Dec 13, 2022 | E-0023 | Establish policies and procedures for medical documentation. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 7, 2023 |
| Dec 13, 2022 | E-0024 | Establish policies and procedures for volunteers. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 7, 2023 |
| Dec 13, 2022 | E-0030 | List the names and contact information of those in the facility. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 7, 2023 |
| Dec 13, 2022 | E-0041 | Implement emergency and standby power systems. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 7, 2023 |
| Dec 13, 2022 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 7, 2023 |
| Dec 13, 2022 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 7, 2023 |
| Dec 13, 2022 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 7, 2023 |
| Dec 13, 2022 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 7, 2023 |
| Dec 13, 2022 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 7, 2023 |
| Dec 13, 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 Mar 7, 2023 |
| Dec 13, 2022 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 7, 2023 |
| Dec 13, 2022 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 7, 2023 |
| Dec 13, 2022 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 7, 2023 |
| Dec 13, 2022 | 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 | F · Potential harm Widespread | Corrected Mar 7, 2023 |
| Dec 13, 2022 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 7, 2023 |
| Dec 13, 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 Mar 7, 2023 |
| Dec 13, 2022 | 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 Mar 7, 2023 |
| Dec 13, 2022 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 7, 2023 |
| Dec 13, 2022 | F-0565 | Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Feb 22, 2023 |
| Dec 13, 2022 | F-0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Feb 22, 2023 |
| Dec 13, 2022 | 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 Feb 22, 2023 |
| Dec 13, 2022 | 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 Feb 22, 2023 |
| Dec 13, 2022 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 20, 2023 |
| Dec 13, 2022 | F-0625 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Feb 22, 2023 |
| Dec 13, 2022 | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 22, 2023 |
| Dec 13, 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 Feb 22, 2023 |
| Dec 13, 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 Feb 22, 2023 |
| Dec 13, 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 | D · Potential harm Isolated | Corrected Feb 22, 2023 |
| Dec 13, 2022 | 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 Feb 22, 2023 |
| Dec 13, 2022 | 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 Feb 22, 2023 |
| Dec 13, 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 Mar 20, 2023 |
| Dec 13, 2022 | 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 Feb 22, 2023 |
| Dec 13, 2022 | F-0744 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 22, 2023 |
| Dec 13, 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 Feb 22, 2023 |
| Dec 13, 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 Feb 22, 2023 |
| Dec 13, 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 Mar 20, 2023 |
| Dec 13, 2022 | 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 Feb 22, 2023 |
| Dec 13, 2022 | F-0807 | Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Feb 22, 2023 |
| Dec 13, 2022 | 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 Feb 22, 2023 |
| Dec 13, 2022 | F-0868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Feb 22, 2023 |
| Dec 13, 2022 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Feb 22, 2023 |
| Dec 13, 2022 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Feb 22, 2023 |
| Dec 13, 2022 | F-0887 | 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. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Mar 20, 2023 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 4.09 (case-mix index 1.21).
| Organization |
| Operational / managerial control |
| OPERATIONAL/MANAGERIAL CONTROL |
| not provided |
| Jan 1, 2005 |
| Kiley Brooks | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Feb 15, 2022 |
| Jeff Gannon | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Feb 15, 2022 |
| Joseph Tutera | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jan 1, 2005 |
| Kiley Brooks | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Jun 1, 2013 |
| Jeff Gannon | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Feb 15, 2022 |
| 60 |
| Jun 29, 2026 |
791 IJ1 harm |
| $29k |
| Stratford Commons Rehab & Health Care Center 12340 Quivira Road, Overland Park, KS 66213 CCN 175549 | 60 | Nov 18, 2025 | 801 IJ | $16k |