Cycle 1
Health 2025-05-06 · Fire 2025-05-06
4 health deficiencies
Top issue: Administration (1 deficiency)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Moundridge, KS
Pine Village
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
86 Twenty-Second Avenue, Moundridge, KS
(620) 345-2901
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
74
Certified beds
Average residents
66
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-04-01
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
Staffing
Hours and turnover
RN hours / resident day
0.52
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.21
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
3.70
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
5.43
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.73
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.56
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
0.01
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.63
CMS adjusted RN staffing hours
Adjusted total hours
6.53
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,129
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.58
Composite VBP score used to determine payment impact.
Payment multiplier
1.0148
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
3.71
Baseline 6.38% · Performance 6.73% · Measure score 3.71 · Achievement 3.71 · Improvement 0
Total nurse turnover
4.16
Baseline 54.64% · Performance 46.67% · Measure score 4.16 · Achievement 4.16 · Improvement 2.18
Adjusted total nurse staffing
10
Baseline 5.13 hours · Performance 6.29 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.34% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 54 · Observed rate 1.85% · Lower 95% interval 5.79% |
| Discharge to community | 26.2% |
50.57%
24.4 pts worse
|
Worse than the National Rate · Eligible stays 35 · Observed rate 11.43% · Lower 95% interval 17.44% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.37% |
95.27%
2.1 pts better
|
Numerator 37 · Denominator 38 |
| Falls with major injury | 2.63% |
0.77%
1.9 pts worse
|
Numerator 1 · Denominator 38 |
| Discharge self-care score | 25.93% |
53.69%
27.8 pts worse
|
Numerator 7 · Denominator 27 |
| Discharge mobility score | 11.11% |
50.94%
39.8 pts worse
|
Numerator 3 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 2.63% |
2.29%
0.3 pts worse
|
Numerator 1 · Denominator 38 · Adjusted rate 2.27% |
| Healthcare-associated infections requiring hospitalization | 6.72% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 29 · Observed rate 3.45% · Lower 95% interval 2.69% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 207 |
| Staff flu vaccination coverage | 36.23% |
42%
5.8 pts worse
|
Numerator 75 · Denominator 207 |
| Discharge function score | 18.52% |
56.45%
37.9 pts worse
|
Numerator 5 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 45% |
25.2%
19.8 pts better
|
Numerator 9 · Denominator 20 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.8
0.8 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
2.2
0.5 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.5% |
91.8%
2.7 pts better
|
93.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.4% · Q2 98.4% · Q3 96.9% · Q4 89.1% · 4Q avg 94.5% |
| 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 | 7.1% |
4.4%
2.7 pts worse
|
3.3%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 4.7% · Q3 6.2% · Q4 10.9% · 4Q avg 7.1% · 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 3.3% · Q2 5.2% · Q3 1.6% · Q4 3.2% · 4Q avg 3.3% |
| Percentage of long-stay residents who lose too much weight | 1.4% |
5.0%
3.6 pts better
|
5.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.8% · Q3 0.0% · Q4 1.9% · 4Q avg 1.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.1% |
23.2%
10.1 pts better
|
19.6%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 12.7% · Q3 10.5% · Q4 10.9% · 4Q avg 13.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.6% |
19.8%
10.2 pts better
|
16.7%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 8.3% · Q3 7.8% · Q4 10.2% · 4Q avg 9.6% · 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 | 21.9% |
18.4%
3.5 pts worse
|
16.3%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.0% · Q2 19.8% · Q3 19.5% · Q4 15.8% · 4Q avg 21.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 34.1% |
18.8%
15.3 pts worse
|
14.9%
19.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.8% · Q2 23.1% · Q3 38.2% · Q4 38.9% · 4Q avg 34.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.8%
1.8 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.9% |
3.1%
3.8 pts worse
|
1.7%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 4.7% · Q3 6.3% · Q4 6.7% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.9% |
23.2%
0.7 pts worse
|
19.8%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 31.4% · Q3 22.0% · Q4 16.3% · 4Q avg 23.9% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
4.6%
1.4 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.5% · Q3 3.9% · Q4 3.5% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.7% |
75.6%
3.1 pts better
|
81.7%
3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 93.1% · Q2 72.4% · Q3 76.0% · Q4 72.0% · 4Q avg 78.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.0% |
11.7%
7.7 pts better
|
12.0%
8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.0% · Observed 3.6% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 7.8% |
2.2%
5.6 pts worse
|
1.6%
6.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.8% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.3% |
73.5%
5.8 pts better
|
79.7%
0.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.7% |
23.0%
8.7 pts worse
|
23.9%
7.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.7% · Observed 28.6% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-31 · Fire 2023-08-31
4 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-12-21 · Fire 2021-12-21
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-06
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-06-12
F · Potential for more than minimal harm
2025-05-06
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 2025-06-12
F · Potential for more than minimal harm
2025-05-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-12
F · Potential for more than minimal harm
2025-05-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-12
F · Potential for more than minimal harm
2025-05-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-18
F · Potential for more than minimal harm
2025-05-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-12
F · Potential for more than minimal harm
2025-05-06
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-12
F · Potential for more than minimal harm
2025-05-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-18
F · Potential for more than minimal harm
2025-05-06
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 2025-06-12
F · Potential for more than minimal harm
2025-05-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-19
F · Potential for more than minimal harm
2025-05-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-06-13
E · Potential for more than minimal harm
2025-05-06
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2025-06-12
F · Potential for more than minimal harm
2023-08-31
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-10-10
F · Potential for more than minimal harm
2023-08-31
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 2023-10-10
F · Potential for more than minimal harm
2023-08-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-10
F · Potential for more than minimal harm
2023-08-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-10
F · Potential for more than minimal harm
2023-08-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-10
F · Potential for more than minimal harm
2023-08-31
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-10
F · Potential for more than minimal harm
2021-12-21
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 2022-03-11
F · Potential for more than minimal harm
2021-12-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-03-11
F · Potential for more than minimal harm
2021-12-21
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2022-03-11
F · Potential for more than minimal harm
2021-12-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-03-11
F · Potential for more than minimal harm
2021-12-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-03-11
F · Potential for more than minimal harm
2021-12-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-03-11
D · Potential for more than minimal harm
2021-12-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-03-11
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-06
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 2025-05-23
F · Potential for more than minimal harm
2025-05-06
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 2025-05-23
E · Potential for more than minimal harm
2025-05-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-05-06
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-05-23
F · Potential for more than minimal harm
2023-08-31
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-31
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 2023-09-15
D · Potential for more than minimal harm
2023-08-31
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 2023-09-15
D · Potential for more than minimal harm
2023-08-31
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 2023-09-15
D · Potential for more than minimal harm
2021-12-21
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-01-26
D · Potential for more than minimal harm
2021-12-21
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-01-26
D · Potential for more than minimal harm
2021-12-21
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 2022-01-26
D · Potential for more than minimal harm
2021-12-21
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2022-01-26
D · Potential for more than minimal harm
2021-12-21
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 2022-01-26
Penalties and ownership
What sits behind the stars
Ownership
Memorial Home, Inc.
5% Or Greater Direct Ownership Interest · Organization
Durst, Michelle
Corporate Director · Individual
Elmore, Heather
Corporate Officer · Individual
Goering, Linda
Corporate Director · Individual
Guhr, Leon
Corporate Director · Individual
Loganbill, Larry
Corporate Director · Individual
Nuzum, Sara
Corporate Director · Individual
Rempel, Theodore
Corporate Director · Individual
Rosfeld, Erin
Corporate Director · Individual
Stucky, Jason
Operational/Managerial Control · Individual
Stucky, Jason
Corporate Officer · Individual
Stucky, Mark
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Moundridge Manor
Moundridge, KS
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
#2
Schowalter Villa
Hesston, KS
5-star overall rating with 5-star inspections with 6 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Bethesda Home
Goessel, KS
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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