6 health deficiencies
Top issue: Infection Control (2 deficiencies)
14 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Wichita, KS
2-star overall rating with 2-star inspections with $59,829 in total fines with 6 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
2133 S Elizabeth Street, Wichita, KS
(316) 262-4473
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
45
Certified beds
Average residents
40
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2006-01-01
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
RN hours / resident day
0.40
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.09
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
3.67
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
5.16
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.71
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
5.89
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
48%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
768
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
64.06
Composite VBP score used to determine payment impact.
Payment multiplier
1.0186
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
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
4.33
Performance 46.00% · Measure score 4.33 · Achievement 4.33 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
8.49
Baseline 3.71 hours · Performance 5.49 hours · Measure score 8.49 · Achievement 8.49 · Improvement 8.11
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 9 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 12 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 10.96% |
8.2%
2.8 pts better
|
Numerator 8 · Denominator 73 |
| Staff flu vaccination coverage | 26.13% |
42%
15.9 pts worse
|
Numerator 29 · Denominator 111 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.8
0.9 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.2
0.9 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.4 · 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 | 7.8% |
4.4%
3.4 pts worse
|
3.3%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 5.3% · Q3 7.9% · Q4 10.8% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.6% |
5.6%
1 pts worse
|
11.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 8.1% · Q3 0.0% · Q4 2.8% · 4Q avg 6.6% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
5.0%
1.3 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.9% · Q3 3.0% · Q4 6.2% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.3% |
23.2%
6.9 pts better
|
19.6%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 11.4% · Q3 17.6% · Q4 26.5% · 4Q avg 16.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.2% |
19.8%
9.6 pts better
|
16.7%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 6.9% · Q3 10.7% · Q4 6.7% · 4Q avg 10.2% · 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 | 22.0% |
18.4%
3.6 pts worse
|
16.3%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 18.9% · 4Q avg 22.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.1% |
18.8%
12.3 pts worse
|
14.9%
16.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.1% · Q2 25.0% · Q3 32.4% · Q4 30.3% · 4Q avg 31.1% · 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 | 3.4% |
3.1%
0.3 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.4% · Q3 8.1% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.6% |
23.2%
11.6 pts better
|
19.8%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.3% · Q2 7.8% · Q3 10.1% · Q4 8.2% · 4Q avg 11.6% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
4.6%
2.2 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.9% · Q3 2.1% · Q4 2.2% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
75.6%
24.4 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
Survey summary
Top issue: Infection Control (2 deficiencies)
14 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Nursing and Physician Services (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-11-14
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-11-14
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-11-14
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-11-14
Fire Safety
Meet other general requirements.
Corrected 2024-11-14
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-14
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2024-11-14
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-14
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-14
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-11-14
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-14
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-14
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-14
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-11-14
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-03-10
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-03-10
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 2023-03-10
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-10
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-10
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-10
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-10
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2023-03-10
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-10
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-03-10
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-08-17
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-08-17
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-08-17
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-10
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 2024-10-10
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 2024-10-10
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 2024-10-10
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-10
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-10-15
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 2024-01-13
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-01-13
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-01-25
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-01-25
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 2023-01-25
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 2023-01-25
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-01-25
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-01-25
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 2023-01-25
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-01-25
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2021-07-23
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 2021-07-23
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2021-07-23
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2021-07-23
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 2021-07-23
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 2021-07-23
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 2021-07-23
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-07-23
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2021-07-23
Penalties and ownership
Fine · fine $37,375
Fine
Payment Denial · denial start 2024-09-26 · 19 days
19 day denial
Fine · fine $22,454
Fine
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
W-2 Managing Employee · Individual
Nearby options
Wichita, KS
3-star overall rating with 3-star inspections with 4 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
Wichita, KS
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Wichita, KS
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
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