Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
MEADOWBROOK REHABILITATION HOSPITAL
GARDNER, KS · 42 certified beds · Last Life Safety survey September 16, 2025
CMS Certification Number 175130 · first certified August 1983
Ownership
Operated by RECOVER-CARE HEALTHCARE · For profit - Limited Liability company
- Ownership changed March 16, 2020 (change of ownership)from PINNACLE HEALTH FACILITIES XVIII LP
Position within KS
22 citations — more than 31% 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 5. With 4 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens May 2027 — about 7 months from now. This facility’s last Life Safety survey was September 2025. 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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6 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 22 Life Safety citations above. The Physical Environment Index
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 | 22 |
| Median facility in KS | 27 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| March 16, 2022 | 6 |
| January 25, 2024 | 7 |
| April 7, 2025 | 2 |
| September 16, 2025 | 7 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0712 | Have simulated fire drills held at unexpected times. | 3 | 2025-09-16 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 2 | 2024-01-25 |
| K-0161 | Use approved construction type or materials. | 2 | 2025-09-16 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-09-16 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2025-09-16 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2025-09-16 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 2 | 2024-01-25 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2025-09-16 |
What the citations cover
- Smoke Deficiencies 10
- Miscellaneous Deficiencies 6
- Egress Deficiencies 2
- Construction Deficiencies 2
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 10 |
| Miscellaneous Deficiencies | 6 |
| Egress Deficiencies | 2 |
| Construction Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 16, 2025 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (January 16, 2026) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (January 16, 2026) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (January 16, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (January 16, 2026) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (January 16, 2026) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (January 16, 2026) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (January 16, 2026) |
April 7, 2025 — 2 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 (April 14, 2025) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (April 14, 2025) |
January 25, 2024 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (February 8, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (February 8, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (February 8, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (February 8, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (February 19, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (February 19, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (February 14, 2024) |
March 16, 2022 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| 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. | Deficient, Provider has date of correction (April 18, 2022) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (April 18, 2022) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (April 18, 2022) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (April 18, 2022) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (April 18, 2022) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (June 16, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.