Garnett, KS

Anderson County Hospital Ltcu

5-star overall rating with 4-star inspections with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

421 S Maple Street, Garnett, KS

(785) 204-4016

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

36

Certified beds

Average residents

30

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1991-05-29

CMS approved date

Coverage

Medicaid

Participation flags

Changed ownership

No

Within the last 12 months

Family council

No

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Hospital-based

Yes

CMS reports the provider resides in a hospital

Staffing

Hours and turnover

RN hours / resident day

1.06

Registered nurse staffing · state 0.72 · national 0.68

LPN hours / resident day

0.20

Licensed practical nurse staffing · state 0.67 · national 0.87

Aide hours / resident day

2.63

Nurse aide staffing · state 2.69 · national 2.35

Total nurse hours

3.89

All reported nurse hours · state 4.07 · national 3.89

Licensed hours

1.26

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

3.43

Weekend nurse staffing · state 3.58 · national 3.43

Weekend RN hours

0.90

Weekend registered nurse coverage · state 0.50 · national 0.47

Physical therapist

0.00

Reported PT staffing

Adjusted RN hours

1.48

CMS adjusted RN staffing hours

Adjusted total hours

5.44

CMS adjusted total nurse staffing hours

Case-mix index

0.98

Higher values indicate more complex resident acuity

RN turnover

43%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

56%

Annual nurse turnover · state 50% · national 46%

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Medicare spending per beneficiary	Not Available	1.02	This provider is not required to submit SNF QRP data.
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · This provider is not required to submit SNF QRP data.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Staff COVID-19 vaccination coverage	Not Available	8.2%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.6	1.8 0.2 pts better	1.9 0.3 pts better	Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.3 · Expected 1.5 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	3.0	2.2 0.8 pts worse	1.8 1.2 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.6 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	62.1%	91.8% 29.7 pts worse	93.4% 31.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 91.3% · Q2 25.0% · Q3 63.0% · Q4 69.0% · 4Q avg 62.1%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	96.0%	95.5% 0.5 pts better	95.5% 0.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 96.0%
Percentage of long-stay residents experiencing one or more falls with major injury	2.9%	4.4% 1.5 pts better	3.3% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.2% · Q3 3.7% · Q4 0.0% · 4Q avg 2.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.0%	5.6% 4.6 pts better	11.4% 10.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.0% · Q4 0.0% · 4Q avg 1.0%
Percentage of long-stay residents who lose too much weight	0.0%	5.0% 5 pts better	5.4% 5.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	25.8%	23.2% 2.6 pts worse	19.6% 6.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 23.8% · Q3 18.2% · Q4 36.0% · 4Q avg 25.8%
Percentage of long-stay residents who received an antipsychotic medication	25.0%	19.8% 5.2 pts worse	16.7% 8.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q3 18.2% · Q4 21.7% · 4Q avg 25.0% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	19.6%	18.4% 1.2 pts worse	16.3% 3.3 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 19.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	23.6%	18.8% 4.8 pts worse	14.9% 8.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 19.0% · Q3 13.6% · Q4 32.0% · 4Q avg 23.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.9%	1.8% 0.1 pts worse	1.0% 0.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.9%	3.1% 0.2 pts better	1.7% 1.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.2% · Q3 3.7% · Q4 3.4% · 4Q avg 2.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	22.2%	23.2% 1 pts better	19.8% 2.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 26.3% · Q3 13.0% · Q4 24.7% · 4Q avg 22.2%
Percentage of long-stay residents with pressure ulcers	1.8%	4.6% 2.8 pts better	5.1% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-13 · Fire 2025-02-13

9 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

3 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Cycle 2 Health 2023-04-05 · Fire 2023-04-05

0 health deficiencies

No concentrated health issue counts in this cycle.

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2021-09-21 · Fire 2021-09-21

7 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

4 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-02-13

E9 · Emergency Preparedness Deficiencies

Fire Safety

Include a process for Emergency Preparedness collaboration.

Corrected 2025-03-21

E · Potential for more than minimal harm 2025-02-13

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-03-21

E · Potential for more than minimal harm 2025-02-13

K222 · Egress Deficiencies

Fire Safety

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.

Corrected 2025-03-21

F · Potential for more than minimal harm 2023-04-05

E30 · Emergency Preparedness Deficiencies

Fire Safety

List the names and contact information of those in the facility.

Corrected 2023-05-05

F · Potential for more than minimal harm 2023-04-05

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-05-05

F · Potential for more than minimal harm 2023-04-05

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-05-05

F · Potential for more than minimal harm 2023-04-05

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2023-05-05

F · Potential for more than minimal harm 2021-09-21

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2021-10-27

F · Potential for more than minimal harm 2021-09-21

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2021-10-27

F · Potential for more than minimal harm 2021-09-21

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2021-10-27

F · Potential for more than minimal harm 2021-09-21

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2021-10-27

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-02-13

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2025-03-25

E · Potential for more than minimal harm 2025-02-13

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-03-25

E · Potential for more than minimal harm 2025-02-13

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2025-03-25

E · Potential for more than minimal harm 2025-02-13

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-25

D · Potential for more than minimal harm 2025-02-13

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2025-03-25

D · Potential for more than minimal harm 2025-02-13

F625 · Resident Rights Deficiencies

Health

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.

Corrected 2025-03-25

D · Potential for more than minimal harm 2025-02-13

F744 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected 2025-03-25

D · Potential for more than minimal harm 2025-02-13

F758 · Pharmacy Service Deficiencies

Health

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.

Corrected 2025-03-25

D · Potential for more than minimal harm 2025-02-13

F849 · Administration Deficiencies

Health

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.

Corrected 2025-03-25

J · Immediate jeopardy 2024-02-13

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-02-04

G · Actual harm 2024-01-23

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-11-28

E · Potential for more than minimal harm 2021-09-21

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2021-10-27

E · Potential for more than minimal harm 2021-09-21

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2021-10-27

D · Potential for more than minimal harm 2021-09-21

F688 · Quality of Life and Care Deficiencies

Health

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.

Corrected 2021-10-27

D · Potential for more than minimal harm 2021-09-21