Moundridge, KS

Moundridge Manor

5-star overall rating with 4-star inspections with $20,295 in total fines with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle

710 N Christian Avenue, Moundridge, KS

(620) 345-6364

Compare this facility

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

78

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

2015-12-23

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

0.73

Registered nurse staffing · state 0.72 · national 0.68

LPN hours / resident day

0.61

Licensed practical nurse staffing · state 0.67 · national 0.87

Aide hours / resident day

3.55

Nurse aide staffing · state 2.69 · national 2.35

Total nurse hours

4.89

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

4.03

Weekend nurse staffing · state 3.58 · national 3.43

Weekend RN hours

0.31

Weekend registered nurse coverage · state 0.50 · national 0.47

Physical therapist

0.02

Reported PT staffing · state 0.04 · national 0.07

Adjusted RN hours

1.03

CMS adjusted RN staffing hours

Adjusted total hours

6.84

CMS adjusted total nurse staffing hours

Case-mix index

0.98

Higher values indicate more complex resident acuity

RN turnover

8%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

20%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

1

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

100

Composite VBP score used to determine payment impact.

Payment multiplier

1.0278

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

10

Baseline 38.18% · Performance 22.55% · Measure score 10 · Achievement 10 · Improvement 9

Adjusted total nurse staffing

10

Baseline 6.23 hours · Performance 6.47 hours · Measure score 10 · Achievement 10 · Improvement 9

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.51%	10.72% 0.2 pts better	No Different than the National Rate · Eligible stays 30 · Observed rate 6.67% · Lower 95% interval 7.09%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	0.7	1.02 0.3 pts better
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 10 · 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 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	8.19%	8.2% About the same	Numerator 19 · Denominator 232
Staff flu vaccination coverage	65.22%	42% 23.2 pts better	Numerator 165 · Denominator 253
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 5 · 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	0.9	1.8 0.9 pts better	1.9 1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.6 · Expected 1.3 · 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 1.2 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.0%	91.8% 6.2 pts better	93.4% 4.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 97.2% · Q2 97.4% · Q3 98.7% · Q4 98.7% · 4Q avg 98.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	97.4%	95.5% 1.9 pts better	95.5% 1.9 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 97.4%
Percentage of long-stay residents experiencing one or more falls with major injury	3.0%	4.4% 1.4 pts better	3.3% 0.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 2.6% · Q3 3.9% · Q4 1.3% · 4Q avg 3.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	7.9%	5.6% 2.3 pts worse	11.4% 3.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 6.8% · Q3 8.1% · Q4 8.2% · 4Q avg 7.9%
Percentage of long-stay residents who lose too much weight	1.8%	5.0% 3.2 pts better	5.4% 3.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 1.4% · Q3 1.4% · Q4 0.0% · 4Q avg 1.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	30.9%	23.2% 7.7 pts worse	19.6% 11.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 31.5% · Q3 32.9% · Q4 29.6% · 4Q avg 30.9%
Percentage of long-stay residents who received an antipsychotic medication	9.2%	19.8% 10.6 pts better	16.7% 7.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 10.2% · Q3 9.5% · Q4 10.8% · 4Q avg 9.2% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	1.3%	0.0% 1.3 pts worse	0.1% 1.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.3% · Q3 1.3% · Q4 1.3% · 4Q avg 1.3%
Percentage of long-stay residents whose ability to walk independently worsened	9.8%	18.4% 8.6 pts better	16.3% 6.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 8.9% · Q3 11.8% · Q4 14.7% · 4Q avg 9.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	14.6%	18.8% 4.2 pts better	14.9% 0.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 14.1% · Q3 11.3% · Q4 17.1% · 4Q avg 14.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.4%	1.8% 1.4 pts better	1.0% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.3%	3.1% 2.8 pts better	1.7% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	16.5%	23.2% 6.7 pts better	19.8% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 22.1% · Q3 8.6% · Q4 19.3% · 4Q avg 16.5%
Percentage of long-stay residents with pressure ulcers	4.2%	4.6% 0.4 pts better	5.1% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 5.4% · Q3 6.1% · Q4 1.9% · 4Q avg 4.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	77.1%	75.6% 1.5 pts better	81.7% 4.6 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 77.1%

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-09-25 · Fire 2024-09-25

3 health deficiencies

Top issue: Administration (1 deficiency)

7 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 2 Health 2023-03-15 · Fire 2023-03-15

4 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2021-08-26 · Fire 2021-08-26

1 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

7 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-09-25

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 2024-11-13

F · Potential for more than minimal harm 2024-09-25

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-11-13

F · Potential for more than minimal harm 2024-09-25

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-11-13

F · Potential for more than minimal harm 2024-09-25

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2024-11-13

F · Potential for more than minimal harm 2024-09-25

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 2024-10-25

D · Potential for more than minimal harm 2024-09-25

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-11-13

D · Potential for more than minimal harm 2024-09-25

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-11-13

F · Potential for more than minimal harm 2023-03-15

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2023-05-26

F · Potential for more than minimal harm 2023-03-15

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-05-26

E · Potential for more than minimal harm 2023-03-15

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-05-26

E · Potential for more than minimal harm 2023-03-15

K325 · Smoke Deficiencies

Fire Safety

Have properly installed hallway dispensers for alcohol-based hand rub.

Corrected 2023-05-26

E · Potential for more than minimal harm 2023-03-15

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-05-26

E · Potential for more than minimal harm 2023-03-15

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-05-26

E · Potential for more than minimal harm 2023-03-15

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 2023-05-26

E · Potential for more than minimal harm 2023-03-15

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-05-26

D · Potential for more than minimal harm 2023-03-15

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-05-26

F · Potential for more than minimal harm 2021-08-26

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 2021-08-26

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2021-10-13

E · Potential for more than minimal harm 2021-08-26

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

E · Potential for more than minimal harm 2021-08-26

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 2021-10-13

E · Potential for more than minimal harm 2021-08-26

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2021-10-13

E · Potential for more than minimal harm 2021-08-26

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2021-10-13

E · Potential for more than minimal harm 2021-08-26

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2021-10-13

Inspection history

Recent health citations

G · Actual harm 2024-09-25

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 2024-10-19

E · Potential for more than minimal harm 2024-09-25

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-10-19

D · Potential for more than minimal harm 2024-09-25

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 2024-10-19

J · Immediate jeopardy 2023-04-18

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 2023-04-10

G · Actual harm 2023-03-15

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 2023-04-26

D · Potential for more than minimal harm 2023-03-15

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 2023-04-26

D · Potential for more than minimal harm 2023-03-15

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 2023-04-26

D · Potential for more than minimal harm 2023-03-15

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 2023-04-26

Penalties and ownership

What sits behind the stars

$20,295 2024-09-25

Fine

Fine · fine $20,295

Fine

Ownership

Church Of God In Christ Mennonite

5% Or Greater Direct Ownership Interest · Organization

100% 1 facilities 2015-01-30

Becker, Travis