Cycle 1
Health 2024-09-11 · Fire 2024-09-11
7 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
La Crosse, KS
Locust Grove Village
2-star overall rating with 2-star inspections with abuse icon flag with $19,660 in total fines with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
701 W 6th Street, La Crosse, KS
(785) 222-2574
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
38
Certified beds
Average residents
33
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-06-01
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
Hours and turnover
RN hours / resident day
0.67
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.46
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
4.32
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.13
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.65
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.86
CMS adjusted RN staffing hours
Adjusted total hours
5.52
CMS adjusted total nurse staffing hours
Case-mix index
1.07
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 50% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 17 · 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 12 · 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 8 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 8 · 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 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 64 |
| Staff flu vaccination coverage | 53.4% |
42%
11.4 pts better
|
Numerator 55 · Denominator 103 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| 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 3 · 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 | 0.7 |
1.8
1.1 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.2
1 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
91.8%
6.7 pts better
|
93.4%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.1% · Q3 96.9% · Q4 100.0% · 4Q avg 98.5% |
| 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 | 5.2% |
4.4%
0.8 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 5.9% · Q3 3.1% · Q4 2.9% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.5% |
5.6%
0.1 pts better
|
11.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 6.9% · Q3 7.7% · Q4 0.0% · 4Q avg 5.5% |
| Percentage of long-stay residents who lose too much weight | 6.8% |
5.0%
1.8 pts worse
|
5.4%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 6.1% · Q3 9.4% · Q4 8.8% · 4Q avg 6.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.1% |
23.2%
2.9 pts worse
|
19.6%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 15.2% · Q3 28.1% · Q4 44.1% · 4Q avg 26.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.7% |
19.8%
11.1 pts better
|
16.7%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 4.0% · Q3 11.5% · Q4 15.4% · 4Q avg 8.7% · 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 | 23.4% |
18.4%
5 pts worse
|
16.3%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 28.9% · Q4 25.4% · 4Q avg 23.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.7% |
18.8%
12.9 pts worse
|
14.9%
16.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.4% · Q2 30.0% · Q3 29.0% · Q4 33.3% · 4Q avg 31.7% · 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 | 6.7% |
3.1%
3.6 pts worse
|
1.7%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 11.8% · Q3 6.2% · Q4 2.9% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.5% |
23.2%
0.3 pts worse
|
19.8%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 22.6% · Q3 21.6% · Q4 32.4% · 4Q avg 23.5% |
| Percentage of long-stay residents with pressure ulcers | 6.9% |
4.6%
2.3 pts worse
|
5.1%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 3.7% · Q3 8.1% · Q4 7.3% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.9% |
75.6%
13.3 pts better
|
81.7%
7.2 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 88.9% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-31 · Fire 2023-01-31
4 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-08-12 · Fire 2021-08-12
0 health deficiencies
No concentrated health issue counts in this cycle.
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-09-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-09-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-09-11
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-09-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-09-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-18
F · Potential for more than minimal harm
2023-01-31
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2023-03-30
F · Potential for more than minimal harm
2023-01-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-30
F · Potential for more than minimal harm
2023-01-31
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2023-03-30
E · Potential for more than minimal harm
2023-01-31
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 2023-03-30
E · Potential for more than minimal harm
2023-01-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-30
E · Potential for more than minimal harm
2023-01-31
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-03-30
D · Potential for more than minimal harm
2023-01-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-30
F · Potential for more than minimal harm
2021-08-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-11-04
F · Potential for more than minimal harm
2021-08-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-11-04
F · Potential for more than minimal harm
2021-08-12
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2021-11-04
F · Potential for more than minimal harm
2021-08-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-11-04
E · Potential for more than minimal harm
2021-08-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-11-04
E · Potential for more than minimal harm
2021-08-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-11-04
E · Potential for more than minimal harm
2021-08-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-11-04
E · Potential for more than minimal harm
2021-08-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-11-04
E · Potential for more than minimal harm
2021-08-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-11-04
Inspection history
Recent health citations
J · Immediate jeopardy
2025-08-14
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-09-02
F · Potential for more than minimal harm
2024-09-11
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-10-14
E · Potential for more than minimal harm
2024-09-11
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 2024-10-14
E · Potential for more than minimal harm
2024-09-11
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-09-11
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-09-11
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 2024-10-14
D · Potential for more than minimal harm
2024-09-11
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 2024-10-14
E · Potential for more than minimal harm
2023-01-31
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 2023-03-08
D · Potential for more than minimal harm
2023-01-31
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 2023-03-08
D · Potential for more than minimal harm
2023-01-31
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 2023-03-08
D · Potential for more than minimal harm
2023-01-31
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 2023-03-08
Penalties and ownership
What sits behind the stars
$19,660
2025-08-14
Fine
Fine · fine $19,660
Fine
Ownership
Aldrich, Troy
Operational/Managerial Control · Individual
Aldrich, Troy
Corporate Director · Individual
Baalmann, Ruth
Operational/Managerial Control · Individual
Baalmann, Ruth
Corporate Director · Individual
Baalmann, Ruth
Corporate Officer · Individual
Basgall, Tonya
Operational/Managerial Control · Individual
Basgall, Tonya
Corporate Director · Individual
Basgall, Tonya
Corporate Officer · Individual
Depperschmidt, Amy
Operational/Managerial Control · Individual
Depperschmidt, Amy
Corporate Director · Individual
Depperschmidt, Amy
Corporate Officer · Individual
Holopirek, Kathy
Operational/Managerial Control · Individual
Holopirek, Kathy
Corporate Director · Individual
Holopirek, Rachel
Operational/Managerial Control · Individual
Holopirek, Rachel
Corporate Director · Individual
Ladd, Robert
Operational/Managerial Control · Individual
Rathke, Charlotte
Operational/Managerial Control · Individual
Worthey, Suzi
Operational/Managerial Control · Individual
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1-star overall rating with 1-star inspections with $15,593 in total fines with 20 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
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Hays, KS
5-star overall rating with 5-star inspections with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
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5-star overall rating with 4-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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