Cycle 1
Health 2024-04-24 · Fire 2024-04-24
11 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Wichita, KS
Family Health & Rehabilitation Center
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
639 S Maize Court, Wichita, KS
(316) 425-5600
Overall
3 / 5
CMS overall stars
Health inspections
3 / 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
72
Certified beds
Average residents
64
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2008-04-07
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
0.51
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.37
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
3.30
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
5.18
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.88
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.46
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
5.56
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,200
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.65
Composite VBP score used to determine payment impact.
Payment multiplier
0.9879
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.33
Baseline 20.47% · Performance 20.35% · Measure score 2.33 · Achievement 2.33 · Improvement 0
Healthcare-associated infections
2.48
Baseline 5.37% · Performance 7.09% · Measure score 2.48 · Achievement 2.48 · Improvement 0
Total nurse turnover
0.85
Baseline 79.63% · Performance 72.22% · Measure score 0.85 · Achievement 0 · Improvement 0.85
Adjusted total nurse staffing
7.80
Baseline 5.20 hours · Performance 5.30 hours · Measure score 7.80 · Achievement 7.80 · Improvement 1.21
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.28% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 476 · Observed rate 10.71% · Lower 95% interval 9.38% |
| Discharge to community | 64.84% |
50.57%
14.3 pts better
|
Better than the National Rate · Eligible stays 444 · Observed rate 63.74% · Lower 95% interval 60.51% |
| Medicare spending per beneficiary | 0.75 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 94.43% |
95.27%
0.8 pts worse
|
Numerator 271 · Denominator 287 |
| Falls with major injury | 1.05% |
0.77%
0.3 pts worse
|
Numerator 3 · Denominator 287 |
| Discharge self-care score | 39.74% |
53.69%
13.9 pts worse
|
Numerator 91 · Denominator 229 |
| Discharge mobility score | 45.85% |
50.94%
5.1 pts worse
|
Numerator 105 · Denominator 229 |
| Pressure ulcers or injuries, new or worsened | 2.09% |
2.29%
0.2 pts better
|
Numerator 6 · Denominator 287 · Adjusted rate 2.24% |
| Healthcare-associated infections requiring hospitalization | 7.09% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 254 · Observed rate 6.3% · Lower 95% interval 4.99% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 144 |
| Staff flu vaccination coverage | 9.84% |
42%
32.2 pts worse
|
Numerator 19 · Denominator 193 |
| Discharge function score | 53.28% |
56.45%
3.2 pts worse
|
Numerator 122 · Denominator 229 |
| Transfer of health information to provider | 99.5% |
95.95%
3.5 pts better
|
Numerator 201 · Denominator 202 |
| Transfer of health information to patient | 97.83% |
96.28%
1.5 pts better
|
Numerator 45 · Denominator 46 |
| Resident COVID-19 vaccinations up to date | 22.6% |
25.2%
2.6 pts worse
|
Numerator 33 · Denominator 146 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
1.8
1 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 3.2 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
2.2
1.3 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
91.8%
5.3 pts better
|
93.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 100.0% · Q3 97.6% · Q4 95.1% · 4Q avg 97.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.2% |
95.5%
1.3 pts worse
|
95.5%
1.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 9.2% |
4.4%
4.8 pts worse
|
3.3%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 4.4% · Q3 9.5% · Q4 9.8% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.6%
5.6 pts better
|
11.4%
11.4 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 lose too much weight | 3.8% |
5.0%
1.2 pts better
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 2.6% · Q4 10.5% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.0% |
23.2%
5.2 pts better
|
19.6%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 19.0% · Q3 20.5% · Q4 13.2% · 4Q avg 18.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.5% |
19.8%
12.3 pts better
|
16.7%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 8.3% · Q3 6.1% · Q4 5.9% · 4Q avg 7.5% · 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 | 34.0% |
18.4%
15.6 pts worse
|
16.3%
17.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 34.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.8% |
18.8%
2 pts worse
|
14.9%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 19.5% · Q3 32.4% · Q4 14.3% · 4Q avg 20.8% · 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 3.1% · Q2 2.1% · Q3 0.0% · Q4 2.3% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
3.1%
1.9 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.4% |
23.2%
9.2 pts worse
|
19.8%
12.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.6% · Q2 42.5% · Q3 29.7% · Q4 12.4% · 4Q avg 32.4% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
4.6%
0.5 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 10.8% · Q3 0.0% · Q4 2.3% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.7% |
75.6%
19.1 pts better
|
81.7%
13 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.9% · Q2 95.1% · Q3 95.9% · Q4 94.7% · 4Q avg 94.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.0% |
11.7%
4.7 pts better
|
12.0%
5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.0% · Observed 6.6% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
2.2%
1.5 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.6% · Q3 0.6% · Q4 1.4% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.1% |
73.5%
14.6 pts better
|
79.7%
8.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.1% |
23.0%
0.1 pts worse
|
23.9%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.1% · Observed 21.5% · Expected 22.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-31 · Fire 2022-08-31
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2021-01-07 · Fire 2021-01-07
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-24
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 2024-05-29
F · Potential for more than minimal harm
2024-04-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-29
F · Potential for more than minimal harm
2024-04-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-05-31
F · Potential for more than minimal harm
2024-04-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-05-29
F · Potential for more than minimal harm
2024-04-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-05-29
F · Potential for more than minimal harm
2024-04-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-10
F · Potential for more than minimal harm
2024-04-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-10
F · Potential for more than minimal harm
2024-04-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-29
F · Potential for more than minimal harm
2024-04-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-29
F · Potential for more than minimal harm
2022-08-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-04
F · Potential for more than minimal harm
2022-08-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-11-04
F · Potential for more than minimal harm
2022-08-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-04
E · Potential for more than minimal harm
2022-08-31
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 2022-11-04
E · Potential for more than minimal harm
2022-08-31
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-11-04
F · Potential for more than minimal harm
2021-01-07
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-03-10
F · Potential for more than minimal harm
2021-01-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-03-10
F · Potential for more than minimal harm
2021-01-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-03-10
E · Potential for more than minimal harm
2021-01-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-03-10
E · Potential for more than minimal harm
2021-01-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-03-10
E · Potential for more than minimal harm
2021-01-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-03-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-04-24
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-04-24
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 2024-05-10
E · Potential for more than minimal harm
2024-04-24
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-04-24
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 2024-05-10
E · Potential for more than minimal harm
2024-04-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-04-24
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-24
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 2024-05-10
D · Potential for more than minimal harm
2024-04-24
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 2024-05-10
D · Potential for more than minimal harm
2024-04-24
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 2024-05-10
D · Potential for more than minimal harm
2024-04-24
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-24
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-05-10
F · Potential for more than minimal harm
2022-08-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-25
D · Potential for more than minimal harm
2022-08-31
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-09-25
D · Potential for more than minimal harm
2022-08-31
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 2022-09-25
D · Potential for more than minimal harm
2022-08-31
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 2022-09-25
D · Potential for more than minimal harm
2022-08-31
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-09-25
D · Potential for more than minimal harm
2022-08-31
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 2022-09-25
D · Potential for more than minimal harm
2021-01-07
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 2021-01-30
Penalties and ownership
What sits behind the stars
Ownership
Axiom Healthcare Alliance, LLC
5% Or Greater Direct Ownership Interest · Organization
Lakin, Gregory
5% Or Greater Indirect Ownership Interest · Individual
Wichita Wellness Inc
5% Or Greater Indirect Ownership Interest · Organization
Axiom Consulting LLC
5% Or Greater Indirect Ownership Interest · Organization
Hermes, Frederick
5% Or Greater Indirect Ownership Interest · Individual
Lillie, Matthew
5% Or Greater Indirect Ownership Interest · Individual
Matt Lillie Investments, Inc
5% Or Greater Indirect Ownership Interest · Organization
Evans, Roger
5% Or Greater Indirect Ownership Interest · Individual
Roger Evans Revocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Dennis L. Ross Pod To Trustee Of Dennis L. Ross Living Trust U/A 4/4/1
5% Or Greater Indirect Ownership Interest · Organization
Ross, Ann
5% Or Greater Indirect Ownership Interest · Individual
Ross, Dennis
5% Or Greater Indirect Ownership Interest · Individual
Axiom Healthcare Services LLC
Operational/Managerial Control · Organization
Becnel, Chance
Corporate Director · Individual
Kruse, Brenda
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Rolling Hills Health And Rehab
Wichita, KS
3-star overall rating with 3-star inspections with $39,118 in total fines with 10 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Sandpiper Healthcare & Rehabilitation Center
Wichita, KS
4-star overall rating with 3-star inspections with $16,801 in total fines with 9 recent health deficiencies with 20 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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