Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
DOWNS CARE AND REHAB
DOWNS, KS · 45 certified beds · Last Life Safety survey July 31, 2024
CMS Certification Number 175201 · first certified February 1991
Ownership
Operated by MISSION HEALTH COMMUNITIES · For profit - Limited Liability company
- Ownership changed October 1, 2019 (change of ownership)from DOWNS CARE AND REHABILITATION CENTER LLC
Position within KS
26 citations — more than 44% of the 296 certified nursing homes in KS. Compared within KS rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 7 citations; the earlier surveys in the window averaged 9.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (March 2026 to June 2026), and past the point by which nine in ten KS facilities have been surveyed. This facility’s last Life Safety survey was July 2024. Facilities in KS are typically surveyed 20–22 months after the last one (median 21), measured over 298 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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5 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 26 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- 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.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
How that compares
Compared with the median facility in KS, and nationally. Surveyors differ markedly between states, so the KS figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 26 |
| Median facility in KS | 27 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| July 15, 2021 | 5 |
| August 18, 2022 | 14 |
| July 31, 2024 | 7 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 3 | 2024-07-31 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2024-07-31 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 3 | 2024-07-31 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2024-07-31 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2022-08-18 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2024-07-31 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 2 | 2022-08-18 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2024-07-31 |
What the citations cover
- Smoke Deficiencies 10
- Gas, Vacuum, and Electrical Systems Deficiencies 6
- Miscellaneous Deficiencies 5
- Egress Deficiencies 3
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 10 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 6 |
| Miscellaneous Deficiencies | 5 |
| Egress Deficiencies | 3 |
| Services Deficiencies | 1 |
| Electrical Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
July 31, 2024 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (November 13, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 13, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (November 13, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (November 13, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 13, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (November 13, 2024) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (November 13, 2024) |
August 18, 2022 — 14 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (November 23, 2022) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (November 23, 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. | Deficient, Provider has date of correction (November 23, 2022) |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | Deficient, Provider has date of correction (November 23, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 23, 2022) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (November 23, 2022) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (November 23, 2022) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (November 23, 2022) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 23, 2022) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (November 23, 2022) |
| K-0901 | Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Deficient, Provider has date of correction (November 23, 2022) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (November 23, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (November 23, 2022) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (November 23, 2022) |
July 15, 2021 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (September 12, 2021) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 12, 2021) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (September 12, 2021) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (September 12, 2021) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (September 12, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.