Cycle 1
Health 2025-03-05 · Fire 2025-03-05
9 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Ness City, KS
Ness County Hospital Ltcu DBA Cedar Village
2-star overall rating with 4-star inspections with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
312 Custer Street, Ness City, KS
(785) 798-2291
Overall
2 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
30
Certified beds
Average residents
24
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2004-10-08
CMS approved date
Coverage
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
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data. |
| Medicare spending per beneficiary | Not Available |
1.02
|
This provider is not required to submit SNF QRP data. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · This provider is not required to submit SNF QRP data. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data. |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.8
0.3 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 0.9 · Expected 1.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.2 |
2.2
2 pts worse
|
1.8
2.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.2 · Observed 3.2 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.8%
8.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 10.2% |
4.4%
5.8 pts worse
|
3.3%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 13.6% · Q3 9.5% · Q4 8.7% · 4Q avg 10.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.4% |
5.6%
3.2 pts better
|
11.4%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 0.0% · Q3 0.0% · Q4 4.5% · 4Q avg 2.4% |
| Percentage of long-stay residents who lose too much weight | 8.8% |
5.0%
3.8 pts worse
|
5.4%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 5.0% · Q4 9.5% · 4Q avg 8.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.8% |
23.2%
0.6 pts worse
|
19.6%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 20.0% · Q3 20.0% · Q4 23.8% · 4Q avg 23.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.3% |
19.8%
3.5 pts worse
|
16.7%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 30.0% · 4Q avg 23.3% · 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 | 21.0% |
18.4%
2.6 pts worse
|
16.3%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.7% |
18.8%
10.9 pts worse
|
14.9%
14.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 35.0% · 4Q avg 29.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.0% |
1.8%
1.2 pts worse
|
1.0%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 4.0% · Q3 0.0% · Q4 2.2% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
3.1%
0.3 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 0.0% · Q3 4.8% · Q4 4.3% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.8% |
23.2%
8.4 pts better
|
19.8%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q3 13.2% · Q4 22.2% · 4Q avg 14.8% |
| Percentage of long-stay residents with pressure ulcers | 13.7% |
4.6%
9.1 pts worse
|
5.1%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.2% · Q2 18.1% · Q3 13.4% · Q4 9.2% · 4Q avg 13.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-15 · Fire 2023-05-15
6 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2021-09-16 · Fire 2021-09-16
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
4 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-05
F · Potential for more than minimal harm
2025-03-05
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-05-05
F · Potential for more than minimal harm
2025-03-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-09
F · Potential for more than minimal harm
2025-03-05
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 2025-05-05
E · Potential for more than minimal harm
2025-03-05
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 2025-05-05
E · Potential for more than minimal harm
2025-03-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-28
E · Potential for more than minimal harm
2025-03-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-05
E · Potential for more than minimal harm
2025-03-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-28
F · Potential for more than minimal harm
2023-05-15
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-06-27
F · Potential for more than minimal harm
2023-05-15
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-06-27
F · Potential for more than minimal harm
2023-05-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-27
F · Potential for more than minimal harm
2023-05-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-27
F · Potential for more than minimal harm
2023-05-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-27
F · Potential for more than minimal harm
2023-05-15
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-06-27
F · Potential for more than minimal harm
2023-05-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-27
E · Potential for more than minimal harm
2023-05-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-06-27
E · Potential for more than minimal harm
2023-05-15
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-06-27
E · Potential for more than minimal harm
2023-05-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-27
E · Potential for more than minimal harm
2023-05-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-27
E · Potential for more than minimal harm
2023-05-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-06-27
E · Potential for more than minimal harm
2023-05-15
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-06-27
E · Potential for more than minimal harm
2023-05-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-27
D · Potential for more than minimal harm
2023-05-15
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-06-27
F · Potential for more than minimal harm
2021-09-16
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2021-10-25
F · Potential for more than minimal harm
2021-09-16
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-10-25
E · Potential for more than minimal harm
2021-09-16
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-10-25
E · Potential for more than minimal harm
2021-09-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-10-25
Inspection history
Recent health citations
G · Actual harm
2025-10-20
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 2025-10-28
D · Potential for more than minimal harm
2025-03-05
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-05
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 2025-04-16
D · Potential for more than minimal harm
2025-03-05
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-05
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 2025-04-16
D · Potential for more than minimal harm
2025-03-05
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-05
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 2025-04-16
D · Potential for more than minimal harm
2025-03-05
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 2025-04-16
E · Potential for more than minimal harm
2023-12-05
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-12-28
D · Potential for more than minimal harm
2023-05-15
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 2023-06-30
D · Potential for more than minimal harm
2023-05-15
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-15
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 2023-06-30
D · Potential for more than minimal harm
2023-05-15
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-15
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 2023-06-30
D · Potential for more than minimal harm
2023-05-15
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-06-30
D · Potential for more than minimal harm
2021-09-16
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 2021-10-05
D · Potential for more than minimal harm
2021-09-16
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 2021-10-05
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
Locust Grove Village
La Crosse, KS
2-star overall rating with 2-star inspections with abuse icon flag with $19,660 in total fines with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Good Samaritan Society - Ellis
Ellis, KS
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Trego Co-Lemke Memorial Hospital Ltcu
Wakeeney, KS
4-star overall rating with 3-star inspections with 9 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
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