6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Mcpherson, KS
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
1601 N Main Street, Mcpherson, KS
(620) 241-5360
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
45
Certified beds
Average residents
39
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Mission Health Communities
Operator or chain grouping
Approved since
1999-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
40 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
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
0.63
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.72
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.38
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.72
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.28
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.44
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
0.56
CMS adjusted RN staffing hours
Adjusted total hours
3.30
CMS adjusted total nurse staffing hours
Case-mix index
1.54
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
5,011
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.76
Composite VBP score used to determine payment impact.
Payment multiplier
0.9909
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
6.71
Baseline 16.88% · Performance 18.32% · Measure score 6.71 · Achievement 6.71 · Improvement 0
Healthcare-associated infections
5.86
Baseline 5.33% · Performance 6.08% · Measure score 5.86 · Achievement 5.86 · Improvement 0
Total nurse turnover
2.53
Baseline 60.47% · Performance 53.33% · Measure score 2.53 · Achievement 2.53 · Improvement 1.50
Adjusted total nurse staffing
0
Baseline 3.57 hours · Performance 2.62 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.6% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 69 · Observed rate 5.8% · Lower 95% interval 6.73% |
| Discharge to community | 65.22% |
50.57%
14.6 pts better
|
Better than the National Rate · Eligible stays 54 · Observed rate 64.81% · Lower 95% interval 52.68% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 35 · Denominator 35 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 35 |
| Discharge self-care score | 36.67% |
53.69%
17 pts worse
|
Numerator 11 · Denominator 30 |
| Discharge mobility score | 40% |
50.94%
10.9 pts worse
|
Numerator 12 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 35 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.08% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 31 · Observed rate 0% · Lower 95% interval 2.7% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 61 |
| Staff flu vaccination coverage | 55.67% |
42%
13.7 pts better
|
Numerator 54 · Denominator 97 |
| Discharge function score | 33.33% |
56.45%
23.1 pts worse
|
Numerator 10 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 21 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.8
0.7 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.2
0.7 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
91.8%
7.5 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.3% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| 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 | 2.8% |
4.4%
1.6 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 0.0% · Q3 2.8% · Q4 2.8% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 52.2% |
5.6%
46.6 pts worse
|
11.4%
40.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 52.9% · Q2 45.7% · Q3 54.5% · Q4 56.2% · 4Q avg 52.2% |
| Percentage of long-stay residents who lose too much weight | 7.1% |
5.0%
2.1 pts worse
|
5.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 9.1% · Q4 16.1% · 4Q avg 7.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.3% |
23.2%
10.1 pts worse
|
19.6%
13.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.7% · Q2 30.3% · Q3 35.3% · Q4 29.0% · 4Q avg 33.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 43.2% |
19.8%
23.4 pts worse
|
16.7%
26.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 45.0% · Q3 45.5% · Q4 38.1% · 4Q avg 43.2% · 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 | 13.1% |
18.4%
5.3 pts better
|
16.3%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 11.9% · Q3 14.4% · Q4 18.5% · 4Q avg 13.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.9% |
18.8%
7.9 pts better
|
14.9%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 9.1% · Q3 15.2% · Q4 9.7% · 4Q avg 10.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
1.8%
0.4 pts worse
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.9% · Q3 3.0% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.5% |
3.1%
0.4 pts worse
|
1.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.7% · Q3 5.7% · Q4 2.8% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.0% |
23.2%
0.8 pts worse
|
19.8%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 28.5% · Q3 13.8% · Q4 35.1% · 4Q avg 24.0% |
| Percentage of long-stay residents with pressure ulcers | 6.6% |
4.6%
2 pts worse
|
5.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 10.3% · Q3 7.4% · Q4 5.8% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.6% |
75.6%
14 pts better
|
81.7%
7.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 70.0% · Q2 92.9% · Q3 100.0% · Q4 93.9% · 4Q avg 89.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.1% |
11.7%
5.6 pts better
|
12.0%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.1% · Observed 6.1% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
2.2%
0.9 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q4 4.5% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.2% |
73.5%
12.7 pts better
|
79.7%
6.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 9.4% |
23.0%
13.6 pts better
|
23.9%
14.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.4% · Observed 9.1% · Expected 23.1% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Pharmacy Service (3 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-07-16
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 2025-07-18
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 2025-07-18
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-17
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-07-16
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-18
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-07-17
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-07-17
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-07-16
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-07-08
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-07-17
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-07-16
Fire Safety
Meet other general requirements.
Corrected 2023-10-09
Fire Safety
Use approved construction type or materials.
Corrected 2023-10-09
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-09
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-10-09
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-09
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-09
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-10-09
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-09
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-10-09
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-03-16
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2022-03-16
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 2022-03-16
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 2022-03-16
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-02-09
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-03-16
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-03-16
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-03-16
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-03-16
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-03-16
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-03-16
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-03-16
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-03-16
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-20
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-05
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-06-05
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-06-05
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 2025-06-05
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-06-05
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-20
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-09-20
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-09-20
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-09-20
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-20
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-09-20
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 2023-09-20
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-20
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 2023-09-20
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 2023-09-20
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-09-20
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2023-09-20
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-02-21
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-02-21
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-02-21
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 2022-02-21
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-02-21
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 2022-02-21
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Nearby options
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3-star overall rating with 3-star inspections with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
Inman, KS
2-star overall rating with 3-star inspections with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Lindsborg, KS
4-star overall rating with 3-star inspections with $8,326 in total fines with 7 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
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