Cycle 1
Health 2025-04-09 · Fire 2025-04-09
5 health deficiencies
Top issue: Infection Control (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Manhattan, KS
Meadowlark Hills
5-star overall rating with 4-star inspections with $8,278 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2121 Meadowlark Road, Manhattan, KS
(785) 537-4610
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
134
Certified beds
Average residents
118
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1988-05-27
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
1.11
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.71
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
5.12
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.82
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.41
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.78
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.25
CMS adjusted RN staffing hours
Adjusted total hours
5.78
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
702
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
65.14
Composite VBP score used to determine payment impact.
Payment multiplier
1.0194
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.49
Baseline 17.73% · Performance 18.42% · Measure score 6.49 · Achievement 6.49 · Improvement 0
Healthcare-associated infections
7.79
Baseline 4.74% · Performance 5.51% · Measure score 7.79 · Achievement 7.79 · Improvement 0
Total nurse turnover
3.53
Baseline 51.11% · Performance 49.26% · Measure score 3.53 · Achievement 3.53 · Improvement 0.20
Adjusted total nurse staffing
8.24
Baseline 4.83 hours · Performance 5.42 hours · Measure score 8.24 · Achievement 8.24 · Improvement 5.74
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.93% |
10.72%
1.8 pts better
|
No Different than the National Rate · Eligible stays 190 · Observed rate 5.26% · Lower 95% interval 5.54% |
| Discharge to community | 60.21% |
50.57%
9.6 pts better
|
Better than the National Rate · Eligible stays 167 · Observed rate 61.08% · Lower 95% interval 53.31% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.25% |
95.27%
4 pts better
|
Numerator 132 · Denominator 133 |
| Falls with major injury | 0.75% |
0.77%
About the same
|
Numerator 1 · Denominator 133 |
| Discharge self-care score | 72.97% |
53.69%
19.3 pts better
|
Numerator 81 · Denominator 111 |
| Discharge mobility score | 63.96% |
50.94%
13 pts better
|
Numerator 71 · Denominator 111 |
| Pressure ulcers or injuries, new or worsened | 3.76% |
2.29%
1.5 pts worse
|
Numerator 5 · Denominator 133 · Adjusted rate 4.91% |
| Healthcare-associated infections requiring hospitalization | 5.51% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 113 · Observed rate 1.77% · Lower 95% interval 3% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 503 |
| Staff flu vaccination coverage | 8.9% |
42%
33.1 pts worse
|
Numerator 46 · Denominator 517 |
| Discharge function score | 70.27% |
56.45%
13.8 pts better
|
Numerator 78 · Denominator 111 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 75 · Denominator 75 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 23 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 33.8% |
25.2%
8.6 pts better
|
Numerator 24 · Denominator 71 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.8
0.5 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.5 · 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 0.9 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
91.8%
8 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
95.5%
3.6 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.1% |
4.4%
0.3 pts better
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.9% · Q3 2.9% · Q4 2.9% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
5.6%
5.1 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 5.4% |
5.0%
0.4 pts worse
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 8.4% · Q3 5.1% · Q4 5.1% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.1% |
23.2%
1.1 pts better
|
19.6%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 24.0% · Q3 19.2% · Q4 19.8% · 4Q avg 22.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.6% |
19.8%
3.2 pts better
|
16.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 18.1% · Q3 18.2% · Q4 10.3% · 4Q avg 16.6% · 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 | 15.2% |
18.4%
3.2 pts better
|
16.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 15.5% · Q3 8.0% · Q4 20.9% · 4Q avg 15.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.6% |
18.8%
2.2 pts better
|
14.9%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.3% · Q2 18.9% · Q3 8.8% · Q4 12.6% · 4Q avg 16.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
1.8%
0.5 pts better
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.0% · Q3 0.9% · Q4 0.9% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.7% |
3.1%
0.4 pts better
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 1.0% · Q3 3.9% · Q4 2.9% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.7% |
23.2%
1.5 pts better
|
19.8%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 19.4% · Q3 21.8% · Q4 25.7% · 4Q avg 21.7% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
4.6%
1.1 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.0% · Q3 2.5% · Q4 3.7% · 4Q avg 3.5% · 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.5% |
11.7%
4.2 pts better
|
12.0%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.5% · Observed 6.4% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.7% |
73.5%
21.2 pts better
|
79.7%
15 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.2% |
23.0%
6.8 pts better
|
23.9%
7.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.2% · Observed 11.7% · Expected 17.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-19 · Fire 2023-07-19
16 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-10-13 · Fire 2021-10-13
9 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-12
F · Potential for more than minimal harm
2025-04-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-12
F · Potential for more than minimal harm
2025-04-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-12
F · Potential for more than minimal harm
2025-04-09
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-05-12
F · Potential for more than minimal harm
2023-07-19
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 2023-08-25
F · Potential for more than minimal harm
2023-07-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-25
F · Potential for more than minimal harm
2023-07-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-25
F · Potential for more than minimal harm
2023-07-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-25
F · Potential for more than minimal harm
2021-10-13
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 2021-12-13
F · Potential for more than minimal harm
2021-10-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-12-13
F · Potential for more than minimal harm
2021-10-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-12-13
E · Potential for more than minimal harm
2021-10-13
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-12-13
E · Potential for more than minimal harm
2021-10-13
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 2021-12-13
E · Potential for more than minimal harm
2021-10-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-12-13
D · Potential for more than minimal harm
2021-10-13
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-12-13
D · Potential for more than minimal harm
2021-10-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-12-13
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-09
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 2025-05-20
E · Potential for more than minimal harm
2025-04-09
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-04-09
F625 · Resident Rights Deficiencies
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 2025-05-20
D · Potential for more than minimal harm
2025-04-09
F849 · Administration Deficiencies
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 2025-05-20
D · Potential for more than minimal harm
2025-04-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-20
G · Actual harm
2025-02-03
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 2025-01-21
E · Potential for more than minimal harm
2024-08-06
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-08-30
E · Potential for more than minimal harm
2023-07-19
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 2023-09-01
D · Potential for more than minimal harm
2023-07-19
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-07-19
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-07-19
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 2023-09-01
D · Potential for more than minimal harm
2023-07-19
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-07-19
F657 · Resident Assessment and Care Planning Deficiencies
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 2023-09-01
D · Potential for more than minimal harm
2023-07-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-07-19
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 2023-09-01
D · Potential for more than minimal harm
2023-07-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-07-19
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-07-19
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 2023-09-01
D · Potential for more than minimal harm
2023-07-19
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-07-19
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 2023-09-01
D · Potential for more than minimal harm
2023-07-19
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 2023-09-01
D · Potential for more than minimal harm
2021-10-13
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2021-10-28
D · Potential for more than minimal harm
2021-10-13
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2021-10-28
D · Potential for more than minimal harm
2021-10-13
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 2021-10-28
D · Potential for more than minimal harm
2021-10-13
F657 · Resident Assessment and Care Planning Deficiencies
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 2021-10-28
D · Potential for more than minimal harm
2021-10-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-10-28
D · Potential for more than minimal harm
2021-10-13
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 2021-10-28
D · Potential for more than minimal harm
2021-10-13
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 2021-10-28
D · Potential for more than minimal harm
2021-10-13
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-10-28
D · Potential for more than minimal harm
2021-10-13
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 2021-10-28
Penalties and ownership
What sits behind the stars
$8,278
2025-02-03
Fine
Fine · fine $8,278
Fine
Ownership
Baker, Lonnie
W-2 Managing Employee · Individual
Manhattan Retirement Foundation Inc.
Operational/Managerial Control · Organization
Nelson, Christopher
Corporate Director · Individual
Nearby options
Other facilities in reach
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Via Christi Village Manhattan, Inc
Manhattan, KS
3-star overall rating with 2-star inspections with $142,185 in total fines with 8 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Stoneybrook Retirement Community
Manhattan, KS
4-star overall rating with 4-star inspections with $13,783 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Good Samaritan Society - Valley Vista
Wamego, KS
4-star overall rating with 3-star inspections with $26,525 in total fines with 11 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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