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

Certified beds

Average residents

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

Staffing

Hours and turnover

RN hours / resident day

0.73

Registered nurse staffing

LPN hours / resident day

0.61

Licensed practical nurse staffing

Aide hours / resident day

3.55

Nurse aide staffing

Weekend hours

4.03

Weekend nurse staffing

RN turnover

Annual RN turnover

Total nurse turnover

20%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

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