Cycle 1
Health 2024-09-11 · Fire 2024-09-11
10 health deficiencies
Top issue: Resident Rights (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Abilene, KS
Memorial Hospital Ltcu (Village Manor)
3-star overall rating with 3-star inspections with $15,593 in total fines with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
705 N Brady Street, Abilene, KS
(785) 263-1431
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
75
Certified beds
Average residents
70
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-04-01
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.44
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.47
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.86
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.77
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
0.92
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.51
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
4.81
CMS adjusted total nurse staffing hours
Case-mix index
1.07
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,140
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.51
Composite VBP score used to determine payment impact.
Payment multiplier
1.0059
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4
Performance 19.58% · Measure score 4 · Achievement 4 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
6.83
Performance 5.79% · Measure score 6.83 · Achievement 6.83 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
4.92
Baseline 70.53% · Performance 45.78% · Measure score 4.92 · Achievement 4.38 · Improvement 4.92
Adjusted total nurse staffing
4.87
Baseline 4.53 hours · Performance 4.46 hours · Measure score 4.87 · Achievement 4.87 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.88% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 78 · Observed rate 12.82% · Lower 95% interval 8.03% |
| Discharge to community | 31.16% |
50.57%
19.4 pts worse
|
Worse than the National Rate · Eligible stays 56 · Observed rate 21.43% · Lower 95% interval 21.3% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 87.18% |
95.27%
8.1 pts worse
|
Numerator 34 · Denominator 39 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 39 |
| Discharge self-care score | 62.07% |
53.69%
8.4 pts better
|
Numerator 18 · Denominator 29 |
| Discharge mobility score | 55.17% |
50.94%
4.2 pts better
|
Numerator 16 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 39 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.79% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 0% · Lower 95% interval 3.21% |
| Staff COVID-19 vaccination coverage | 19.35% |
8.2%
11.2 pts better
|
Numerator 18 · Denominator 93 |
| Staff flu vaccination coverage | 74.11% |
42%
32.1 pts better
|
Numerator 83 · Denominator 112 |
| Discharge function score | 68.97% |
56.45%
12.5 pts better
|
Numerator 20 · Denominator 29 |
| 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 | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| 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
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.8
About the same
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 5.4 |
2.2
3.2 pts worse
|
1.8
3.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.4 · Observed 5.2 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.1% |
91.8%
4.3 pts better
|
93.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.4% · Q2 95.2% · Q3 96.9% · Q4 98.5% · 4Q avg 96.1% |
| 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 | 8.2% |
4.4%
3.8 pts worse
|
3.3%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 8.1% · Q3 7.7% · Q4 9.0% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.3% |
5.6%
2.3 pts better
|
11.4%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 3.4% · Q3 0.0% · Q4 3.2% · 4Q avg 3.3% |
| Percentage of long-stay residents who lose too much weight | 3.8% |
5.0%
1.2 pts better
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 6.7% · Q3 0.0% · Q4 3.4% · 4Q avg 3.8% |
| 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 25.9% · Q2 26.2% · Q3 23.0% · Q4 29.5% · 4Q avg 26.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.7% |
19.8%
6.9 pts worse
|
16.7%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 22.9% · Q3 24.0% · Q4 34.8% · 4Q avg 26.7% · 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 | 20.5% |
18.4%
2.1 pts worse
|
16.3%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 20.4% · Q3 18.4% · Q4 23.1% · 4Q avg 20.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.9% |
18.8%
3.1 pts worse
|
14.9%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 24.1% · Q3 20.3% · Q4 22.8% · 4Q avg 21.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.0% |
1.8%
2.2 pts worse
|
1.0%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 2.9% · Q3 4.4% · Q4 5.4% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.4% |
3.1%
1.3 pts worse
|
1.7%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 1.6% · Q3 3.2% · Q4 1.5% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.7% |
23.2%
3.5 pts better
|
19.8%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 14.8% · Q3 12.2% · Q4 32.2% · 4Q avg 19.7% |
| Percentage of long-stay residents with pressure ulcers | 7.4% |
4.6%
2.8 pts worse
|
5.1%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 4.6% · Q3 6.1% · Q4 12.9% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.8% |
75.6%
18.2 pts better
|
81.7%
12.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 97.1% · Q3 93.5% · Q4 86.7% · 4Q avg 93.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 31.9% |
11.7%
20.2 pts worse
|
12.0%
19.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.9% · Observed 29.2% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.6% |
2.2%
0.4 pts worse
|
1.6%
1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.5% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.2% |
73.5%
15.7 pts better
|
79.7%
9.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.6% |
23.0%
8.4 pts better
|
23.9%
9.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.6% · Observed 12.5% · Expected 20.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-08 · Fire 2023-02-08
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-08-04 · Fire 2021-08-04
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
11 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
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-22
F · Potential for more than minimal harm
2024-09-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-22
F · Potential for more than minimal harm
2024-09-11
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-22
F · Potential for more than minimal harm
2024-09-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-22
F · Potential for more than minimal harm
2024-09-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-22
E · Potential for more than minimal harm
2024-09-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-22
F · Potential for more than minimal harm
2023-02-08
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-03-15
F · Potential for more than minimal harm
2023-02-08
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 2023-04-15
F · Potential for more than minimal harm
2023-02-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-15
F · Potential for more than minimal harm
2023-02-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-15
F · Potential for more than minimal harm
2023-02-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-15
F · Potential for more than minimal harm
2023-02-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-15
F · Potential for more than minimal harm
2023-02-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-04-15
F · Potential for more than minimal harm
2023-02-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-15
F · Potential for more than minimal harm
2023-02-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-15
F · Potential for more than minimal harm
2021-08-04
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2021-10-13
F · Potential for more than minimal harm
2021-08-04
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2021-10-13
F · Potential for more than minimal harm
2021-08-04
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 2021-10-13
F · Potential for more than minimal harm
2021-08-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-10-13
F · Potential for more than minimal harm
2021-08-04
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-09-09
F · Potential for more than minimal harm
2021-08-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-09-09
F · Potential for more than minimal harm
2021-08-04
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-10-13
F · Potential for more than minimal harm
2021-08-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-10-13
F · Potential for more than minimal harm
2021-08-04
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 2021-10-13
F · Potential for more than minimal harm
2021-08-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-10-13
F · Potential for more than minimal harm
2021-08-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-09-09
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-09-11
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-09-11
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 2024-10-16
D · Potential for more than minimal harm
2024-09-11
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-09-11
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-09-11
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 2024-10-16
D · Potential for more than minimal harm
2024-09-11
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 2024-10-16
D · Potential for more than minimal harm
2024-09-11
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-09-11
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-10-16
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 2024-10-16
D · 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 2024-10-16
J · Immediate jeopardy
2023-07-05
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 2023-06-29
G · Actual harm
2023-03-20
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
E · Potential for more than minimal harm
2023-02-08
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
2023-02-08
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-03-08
D · Potential for more than minimal harm
2023-02-08
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 2023-03-08
D · Potential for more than minimal harm
2023-02-08
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 2023-03-08
D · Potential for more than minimal harm
2023-02-08
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
D · Potential for more than minimal harm
2021-08-04
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 2021-08-16
Penalties and ownership
What sits behind the stars
$15,593
2023-07-05
Fine
Fine · fine $15,593
Fine
Ownership
Biggs, James
Corporate Director · Individual
Diehl, Karman
Corporate Director · Individual
Geiger, Anthony
Corporate Director · Individual
Glanzer, Elgin
Operational/Managerial Control · Individual
Haverly, Kimberly
Operational/Managerial Control · Individual
Holmes, Brian
Operational/Managerial Control · Individual
Salina Regional Health Center Inc
Operational/Managerial Control · Organization
Schwarting, Joseph
Corporate Director · Individual
Wyatt, Kent
Corporate Director · Individual
Nearby options
Other facilities in reach
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Enterprise Estates Nursing Center
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1-star overall rating with 1-star inspections with $16,556 in total fines with 11 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Chapman Valley Manor
Chapman, KS
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Holiday Resort Of Salina
Salina, KS
2-star overall rating with 2-star inspections with $16,795 in total fines with 17 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
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