Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
MERRIAM GARDENS HEALTHCARE & REHABILITATION CENTER
MERRIAM, KS · 120 certified beds · Last Life Safety survey January 31, 2025
CMS Certification Number 175123 · first certified February 1981
Ownership
Operated by RECOVER-CARE HEALTHCARE · For profit - Limited Liability company
- Ownership changed October 1, 2019 (change of ownership)to MERRIAM GARDENS HEALTHCARE AND REHABILITATION CENTER from TRINITY NURSING & REHAB CENTER INC.
Position within KS
36 citations — more than 78% 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 1 citation; the earlier surveys in the window averaged 11.7. With 4 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: September 2026 to December 2026. This facility’s last Life Safety survey was January 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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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.
Emergency preparedness
8 of the 36 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
7 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 36 Life Safety citations above. The Physical Environment Index
- 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-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0908 Keep all essential equipment working safely.
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 | 36 |
| Median facility in KS | 27 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 21, 2021 | 11 |
| February 16, 2023 | 9 |
| October 2, 2024 | 15 |
| January 31, 2025 | 1 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2024-10-02 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2024-10-02 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2024-10-02 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2023-02-16 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2024-10-02 |
| 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. | 2 | 2025-01-31 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2024-10-02 |
| E-0009 | Include a process for Emergency Preparedness collaboration. | 2 | 2023-02-16 |
What the citations cover
- Smoke Deficiencies 11
- Emergency Preparedness Deficiencies 8
- Gas, Vacuum, and Electrical Systems Deficiencies 6
- Egress Deficiencies 4
- Other 7
| Category | Citations |
|---|---|
| Smoke Deficiencies | 11 |
| Emergency Preparedness Deficiencies | 8 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 6 |
| Egress Deficiencies | 4 |
| Miscellaneous Deficiencies | 4 |
| Services Deficiencies | 2 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 31, 2025 — 1 citation
| 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 (February 14, 2025) |
October 2, 2024 — 15 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (November 20, 2024) |
| E-0032 | Provide primary/alternate means for communication. | Deficient, Provider has date of correction (November 20, 2024) |
| K-0111 | Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Deficient, Provider has date of correction (November 20, 2024) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (November 20, 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. | Deficient, Provider has date of correction (November 20, 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. | Deficient, Provider has date of correction (November 21, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 21, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (November 21, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (November 20, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (November 20, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 21, 2024) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (November 20, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (November 20, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (November 21, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (November 21, 2024) |
February 16, 2023 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (April 28, 2023) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (April 28, 2023) |
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (April 28, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (April 28, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 28, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (April 28, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (April 28, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (April 28, 2023) |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Deficient, Provider has date of correction (April 28, 2023) |
June 21, 2021 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (August 18, 2021) |
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (August 18, 2021) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (August 18, 2021) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (August 18, 2021) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 18, 2021) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 18, 2021) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (August 18, 2021) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (August 18, 2021) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (August 18, 2021) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (August 18, 2021) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (August 18, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.