Cycle 1
Health 2025-08-14 · Fire 2025-08-14
8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Wichita, KS
Ascension Living Via Christi Village Mclean
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
777 N Mclean Blvd, Wichita, KS
(316) 942-7000
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
36
Certified beds
Average residents
34
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Via Christi Villages
Operator or chain grouping
Approved since
2014-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
2 facilities
Chain averages 5 overall / 5 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.29
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.25
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.72
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.27
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.88
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.92
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.40
CMS adjusted RN staffing hours
Adjusted total hours
4.61
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,033
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.19
Composite VBP score used to determine payment impact.
Payment multiplier
1.0067
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.94
Baseline 19.91% · Performance 18.68% · Measure score 5.94 · Achievement 5.94 · Improvement 3.76
Healthcare-associated infections
7.16
Baseline 7.93% · Performance 5.70% · Measure score 7.16 · Achievement 7.16 · Improvement 7.11
Total nurse turnover
2.70
Baseline 65.12% · Performance 52.63% · Measure score 2.70 · Achievement 2.70 · Improvement 2.6
Adjusted total nurse staffing
5.08
Baseline 3.83 hours · Performance 4.52 hours · Measure score 5.08 · Achievement 5.08 · Improvement 3.05
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.67% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 83 · Observed rate 7.23% · Lower 95% interval 6.29% |
| Discharge to community | 49.49% |
50.57%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 78 · Observed rate 46.15% · Lower 95% interval 38.67% |
| Medicare spending per beneficiary | 0.63 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 68 · Denominator 68 |
| Falls with major injury | 2.94% |
0.77%
2.2 pts worse
|
Numerator 2 · Denominator 68 |
| Discharge self-care score | 55.93% |
53.69%
2.2 pts better
|
Numerator 33 · Denominator 59 |
| Discharge mobility score | 40.68% |
50.94%
10.3 pts worse
|
Numerator 24 · Denominator 59 |
| Pressure ulcers or injuries, new or worsened | 1.47% |
2.29%
0.8 pts better
|
Numerator 1 · Denominator 68 · Adjusted rate 1.89% |
| Healthcare-associated infections requiring hospitalization | 5.69% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 45 · Observed rate 0% · Lower 95% interval 3.03% |
| Staff COVID-19 vaccination coverage | 1.45% |
8.2%
6.7 pts worse
|
Numerator 1 · Denominator 69 |
| Staff flu vaccination coverage | 61.25% |
42%
19.2 pts better
|
Numerator 49 · Denominator 80 |
| Discharge function score | 57.63% |
56.45%
1.2 pts better
|
Numerator 34 · Denominator 59 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 35 · Denominator 35 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 36.59% |
25.2%
11.4 pts better
|
Numerator 15 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.8
0.4 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.7 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
2.2
1.2 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.8%
8.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.5%
4.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.0% |
4.4%
3.6 pts worse
|
3.3%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 6.9% · Q3 11.1% · Q4 11.1% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.1% |
5.6%
1.5 pts better
|
11.4%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.0% · Q3 13.0% · Q4 0.0% · 4Q avg 4.1% |
| Percentage of long-stay residents who lose too much weight | 1.0% |
5.0%
4 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.5% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.3% |
23.2%
4.1 pts worse
|
19.6%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 32.0% · Q3 26.1% · Q4 16.7% · 4Q avg 27.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.3% |
19.8%
0.5 pts worse
|
16.7%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 20.0% · Q4 25.0% · 4Q avg 20.3% · 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 | 18.6% |
18.4%
0.2 pts worse
|
16.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.7% |
18.8%
4.1 pts better
|
14.9%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 12.5% · Q3 21.7% · Q4 13.0% · 4Q avg 14.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.8%
1.8 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
3.1%
2.2 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · 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 22.8% · Q2 35.3% · Q3 19.3% · Q4 11.3% · 4Q avg 22.2% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
4.6%
0.4 pts worse
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 4.0% · Q3 0.0% · Q4 4.0% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
75.6%
24 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.8% |
11.7%
1.1 pts worse
|
12.0%
0.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.8% · Observed 12.3% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.8% |
73.5%
21.3 pts better
|
79.7%
15.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.1% |
23.0%
3.9 pts better
|
23.9%
4.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.1% · Observed 19.3% · Expected 24.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-15 · Fire 2023-11-15
6 health deficiencies
Top issue: Environmental (2 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2022-05-31 · Fire 2022-05-31
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-11-18
F · Potential for more than minimal harm
2025-08-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-10-02
F · Potential for more than minimal harm
2025-08-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-02
F · Potential for more than minimal harm
2023-11-15
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-11-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-11-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-01-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-14
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-09-10
D · Potential for more than minimal harm
2025-08-14
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-09-10
D · Potential for more than minimal harm
2025-08-14
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-09-10
D · Potential for more than minimal harm
2025-08-14
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-10
D · Potential for more than minimal harm
2025-08-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-09-10
D · Potential for more than minimal harm
2025-08-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-09-10
D · Potential for more than minimal harm
2025-08-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-10
D · Potential for more than minimal harm
2025-08-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-10
G · Actual harm
2023-11-15
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 2023-12-01
F · Potential for more than minimal harm
2023-11-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-01
F · Potential for more than minimal harm
2023-11-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-11-15
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-11-15
F923 · Environmental Deficiencies
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-11-15
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-12-01
Penalties and ownership
What sits behind the stars
Ownership
Via Christi Villages Inc
5% Or Greater Direct Ownership Interest · Organization
Ascension Health Senior Care
Operational/Managerial Control · Organization
Mccue, Tamara
Operational/Managerial Control · Individual
Musgrave, Lisa
Corporate Officer · Individual
Polley, Valan
Operational/Managerial Control · Individual
Shadbolt, Erin
Corporate Director · Individual
Smoot, Kenneth
Corporate Director · Individual
Nearby options
Other facilities in reach
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Meridian Rehabilitation And Health Care Center
Wichita, KS
2-star overall rating with 1-star inspections with abuse icon flag with $84,501 in total fines with 20 recent health deficiencies with 21 fire-safety deficiencies in the latest cycle
#2
Lakepoint Wichita, LLC
Wichita, KS
2-star overall rating with 2-star inspections with $18,342 in total fines with 12 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#3
Wichita Presbyterian Manor
Wichita, KS
4-star overall rating with 4-star inspections with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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