Cycle 1
Health 2024-08-07 · Fire 2024-08-07
7 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Colby, KS
Citizens Medical Center Ltcu
4-star overall rating with 4-star inspections with $17,124 in total fines with 7 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
1625 S Franklin Avenue, Colby, KS
(785) 462-8295
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
60
Certified beds
Average residents
43
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2017-01-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
1.27
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.14
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.52
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.93
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.23
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
0.02
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.48
CMS adjusted RN staffing hours
Adjusted total hours
4.58
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,044
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.18
Composite VBP score used to determine payment impact.
Payment multiplier
0.9882
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0.98
Baseline 47.62% · Performance 59.68% · Measure score 0.98 · Achievement 0.98 · Improvement 0
Adjusted total nurse staffing
5.86
Baseline 4.04 hours · Performance 4.74 hours · Measure score 5.86 · Achievement 5.86 · Improvement 3.55
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.04% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 5.71% · Lower 95% interval 5.87% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 82.05% |
95.27%
13.2 pts worse
|
Numerator 32 · Denominator 39 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 39 |
| Discharge self-care score | 30% |
53.69%
23.7 pts worse
|
Numerator 9 · Denominator 30 |
| Discharge mobility score | 46.67% |
50.94%
4.3 pts worse
|
Numerator 14 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 2.56% |
2.29%
0.3 pts worse
|
Numerator 1 · Denominator 39 · Adjusted rate 2.19% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.23% |
8.2%
7 pts worse
|
Numerator 1 · Denominator 81 |
| Staff flu vaccination coverage | 74.23% |
42%
32.2 pts better
|
Numerator 121 · Denominator 163 |
| Discharge function score | 36.67% |
56.45%
19.8 pts worse
|
Numerator 11 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.8
0.5 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
2.2
0.4 pts better
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.6 · 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 | 4.7% |
4.4%
0.3 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 7.1% · Q3 2.3% · Q4 2.4% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.8% |
5.6%
7.2 pts worse
|
11.4%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 7.7% · Q3 11.4% · Q4 14.6% · 4Q avg 12.8% |
| Percentage of long-stay residents who lose too much weight | 3.8% |
5.0%
1.2 pts better
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 7.5% · Q3 0.0% · Q4 2.4% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 48.8% |
23.2%
25.6 pts worse
|
19.6%
29.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 50.0% · Q2 53.7% · Q3 42.9% · Q4 48.8% · 4Q avg 48.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.5% |
19.8%
8.3 pts better
|
16.7%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 15.2% · Q3 5.6% · Q4 10.8% · 4Q avg 11.5% · 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 | 18.7% |
18.4%
0.3 pts worse
|
16.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 14.0% · Q3 26.3% · Q4 21.6% · 4Q avg 18.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.1% |
18.8%
7.3 pts worse
|
14.9%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 22.9% · Q3 33.3% · Q4 26.5% · 4Q avg 26.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
1.8%
0.8 pts better
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 1.8% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
3.1%
2.5 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.6% |
23.2%
4.6 pts better
|
19.8%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 24.3% · Q3 21.4% · Q4 16.6% · 4Q avg 18.6% |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
4.6%
1.1 pts worse
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.9% · Q3 6.3% · Q4 6.1% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
75.6%
22.5 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 98.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
11.7%
11.7 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 10.3% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.6% |
23.0%
3.4 pts better
|
23.9%
4.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.6% · Observed 18.2% · Expected 22.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-13 · Fire 2022-10-13
6 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-08-19 · Fire 2021-08-19
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-07
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-09-18
F · Potential for more than minimal harm
2024-08-07
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-09-18
F · Potential for more than minimal harm
2024-08-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-18
F · Potential for more than minimal harm
2024-08-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-18
E · Potential for more than minimal harm
2024-08-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-18
E · Potential for more than minimal harm
2024-08-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-18
E · Potential for more than minimal harm
2024-08-07
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-09-18
E · Potential for more than minimal harm
2024-08-07
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-18
D · Potential for more than minimal harm
2024-08-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-18
F · Potential for more than minimal harm
2022-10-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-08
F · Potential for more than minimal harm
2022-10-13
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2022-12-08
E · Potential for more than minimal harm
2022-10-13
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 2022-12-08
E · Potential for more than minimal harm
2022-10-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-08
E · Potential for more than minimal harm
2022-10-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-12-08
E · Potential for more than minimal harm
2022-10-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-10-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-12-08
E · Potential for more than minimal harm
2021-08-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-09-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-08-07
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-08-07
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-08-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-08-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-08-07
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 2024-08-16
D · Potential for more than minimal harm
2024-08-07
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-08-07
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 2024-08-16
J · Immediate jeopardy
2024-06-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-31
G · Actual harm
2022-10-13
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-11-05
D · Potential for more than minimal harm
2022-10-13
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-11-05
D · Potential for more than minimal harm
2022-10-13
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-11-05
D · Potential for more than minimal harm
2022-10-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-11-05
D · Potential for more than minimal harm
2022-10-13
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-11-05
D · Potential for more than minimal harm
2021-08-19
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2021-08-30
D · Potential for more than minimal harm
2021-08-19
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-08-30
D · Potential for more than minimal harm
2021-08-19
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 2021-08-30
D · Potential for more than minimal harm
2021-08-19
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 2021-08-30
Penalties and ownership
What sits behind the stars
$17,124
2024-06-05
Fine
Fine · fine $17,124
Fine
Ownership
Citizens Medical Center Inc
Operational/Managerial Control · Organization
Dixon, Heather
W-2 Managing Employee · Individual
Mccorkle, David
Operational/Managerial Control · Individual
Mccorkle, David
Corporate Officer · Individual
Mccorkle, David
W-2 Managing Employee · Individual
Stover, Philip
Operational/Managerial Control · Individual
Stover, Philip
Corporate Officer · Individual
Stover, Philip
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Colby Operator, LLC
Colby, KS
3-star overall rating with 3-star inspections with $40,381 in total fines with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Logan County Senior Living Inc
Oakley, KS
2-star overall rating with 2-star inspections with $98,346 in total fines with 12 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Good Samaritan Society - Atwood
Atwood, KS
2-star overall rating with 1-star inspections with $68,956 in total fines with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
Jump out