Cycle 1
Health 2024-10-09 · Fire 2024-10-09
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Wichita, KS
Larksfield Place
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
2828 N. Governeour, Wichita, KS
(316) 636-1111
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
77
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-03-06
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
0.67
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.39
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
3.19
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
5.25
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
2.05
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.68
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.60
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
5.55
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,662
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.05
Composite VBP score used to determine payment impact.
Payment multiplier
0.9921
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.01
Baseline 18.88% · Performance 20.96% · Measure score 1.01 · Achievement 1.01 · Improvement 0
Healthcare-associated infections
2.66
Baseline 4.80% · Performance 7.04% · Measure score 2.66 · Achievement 2.66 · Improvement 0
Total nurse turnover
3.43
Baseline 51.58% · Performance 49.66% · Measure score 3.43 · Achievement 3.43 · Improvement 0.22
Adjusted total nurse staffing
8.52
Baseline 4.93 hours · Performance 5.50 hours · Measure score 8.52 · Achievement 8.52 · Improvement 6.21
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.88% |
10.72%
1.8 pts better
|
No Different than the National Rate · Eligible stays 409 · Observed rate 7.33% · Lower 95% interval 6.67% |
| Discharge to community | 60.06% |
50.57%
9.5 pts better
|
Better than the National Rate · Eligible stays 401 · Observed rate 56.86% · Lower 95% interval 55.07% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.74% |
95.27%
3.5 pts better
|
Numerator 236 · Denominator 239 |
| Falls with major injury | 0.42% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 239 |
| Discharge self-care score | 46.46% |
53.69%
7.2 pts worse
|
Numerator 92 · Denominator 198 |
| Discharge mobility score | 54.55% |
50.94%
3.6 pts better
|
Numerator 108 · Denominator 198 |
| Pressure ulcers or injuries, new or worsened | 1.67% |
2.29%
0.6 pts better
|
Numerator 4 · Denominator 239 · Adjusted rate 1.84% |
| Healthcare-associated infections requiring hospitalization | 7.04% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 223 · Observed rate 5.83% · Lower 95% interval 4.25% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 214 |
| Staff flu vaccination coverage | 52.99% |
42%
11 pts better
|
Numerator 133 · Denominator 251 |
| Discharge function score | 56.57% |
56.45%
0.1 pts better
|
Numerator 112 · Denominator 198 |
| Transfer of health information to provider | 89.19% |
95.95%
6.8 pts worse
|
Numerator 165 · Denominator 185 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 49.58% |
25.2%
24.4 pts better
|
Numerator 59 · Denominator 119 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.8
0.1 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.9 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
2.2
1.1 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.6 · 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 | 96.4% |
95.5%
0.9 pts better
|
95.5%
0.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
4.4%
0.7 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 6.0% · Q3 4.2% · Q4 2.0% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.4% |
5.6%
1.8 pts worse
|
11.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 10.0% · Q3 10.9% · Q4 2.1% · 4Q avg 7.4% |
| Percentage of long-stay residents who lose too much weight | 5.5% |
5.0%
0.5 pts worse
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 6.1% · Q3 3.2% · Q4 6.5% · 4Q avg 5.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.8% |
23.2%
14.4 pts better
|
19.6%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 5.7% · Q3 6.1% · Q4 11.8% · 4Q avg 8.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.2% |
19.8%
14.6 pts better
|
16.7%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 7.1% · Q3 6.9% · Q4 3.6% · 4Q avg 5.2% · 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 | 13.0% |
18.4%
5.4 pts better
|
16.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 10.8% · 4Q avg 13.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.7% |
18.8%
10.1 pts better
|
14.9%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 3.0% · Q3 6.5% · Q4 15.6% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
1.8%
0.3 pts better
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.4% · Q3 0.0% · Q4 2.3% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
3.1%
2 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.3% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.5% |
23.2%
1.3 pts worse
|
19.8%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 19.1% · Q3 23.3% · Q4 37.2% · 4Q avg 24.5% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
4.6%
0.1 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 3.8% · Q3 8.0% · Q4 1.9% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
75.6%
22.7 pts better
|
81.7%
16.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.5% · Q2 99.1% · Q3 96.7% · Q4 97.8% · 4Q avg 98.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.1% |
11.7%
1.6 pts better
|
12.0%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.1% · Observed 9.2% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
2.2%
1.7 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.6% · Q3 0.0% · Q4 0.6% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.2% |
73.5%
23.7 pts better
|
79.7%
17.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.1% |
23.0%
3.1 pts worse
|
23.9%
2.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.1% · Observed 23.6% · Expected 21.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-21 · Fire 2022-12-21
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-05-05 · Fire 2021-05-05
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-09
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-10-09
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-10-09
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-10-09
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-10-09
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-10-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-10-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-10-09
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-09
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2024-11-15
F · Potential for more than minimal harm
2022-12-21
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 2023-03-09
F · Potential for more than minimal harm
2022-12-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-09
F · Potential for more than minimal harm
2022-12-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-09
F · Potential for more than minimal harm
2022-12-21
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-03-09
F · Potential for more than minimal harm
2022-12-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-09
F · Potential for more than minimal harm
2022-12-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-09
F · Potential for more than minimal harm
2022-12-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-09
E · Potential for more than minimal harm
2022-12-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-09
E · Potential for more than minimal harm
2021-05-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-06-24
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-10-09
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 2024-11-15
D · Potential for more than minimal harm
2024-10-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-09
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 2024-11-15
D · Potential for more than minimal harm
2024-10-09
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 2024-11-15
D · Potential for more than minimal harm
2024-10-09
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 2024-11-15
D · Potential for more than minimal harm
2024-10-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-15
F · Potential for more than minimal harm
2022-12-21
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 2023-01-20
D · Potential for more than minimal harm
2022-12-21
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-01-20
F · Potential for more than minimal harm
2021-05-05
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 2021-05-31
E · Potential for more than minimal harm
2021-05-05
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 2021-05-31
D · Potential for more than minimal harm
2021-05-05
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 2021-05-31
D · Potential for more than minimal harm
2021-05-05
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 2021-05-31
Penalties and ownership
What sits behind the stars
Ownership
Braun, Shannon
Corporate Director · Individual
Brown, Ronald
Corporate Director · Individual
Dietz, Connie
Corporate Director · Individual
Dillard, Stephen
Corporate Director · Individual
Gear, David
Corporate Director · Individual
Griffin, Michael
Operational/Managerial Control · Individual
Griffin, Michael
Corporate Officer · Individual
Hambley, Michael
Operational/Managerial Control · Individual
Hambley, Michael
Corporate Officer · Individual
Larksfield Place Retirement Communities, Inc.
Operational/Managerial Control · Organization
Mccue, Tamara
Operational/Managerial Control · Individual
Melugin, Gregory
Corporate Director · Individual
Utash, Sheree
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Great Plains Post Acute
Wichita, KS
1-star overall rating with 1-star inspections with Special Focus status with $49,505 in total fines with 23 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#2
Legacy At College Hill
Wichita, KS
1-star overall rating with 1-star inspections with Special Focus status with $96,031 in total fines with 17 recent health deficiencies with 21 fire-safety deficiencies in the latest cycle
#3
Catholic Care Center, Inc
Bel Aire, KS
2-star overall rating with 2-star inspections with 19 recent health deficiencies with 23 fire-safety deficiencies in the latest cycle
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