Liberal, KS

Southwest Medical Center SNF

4-star overall rating with 3-star inspections with 7 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

315 W 15th Street, Liberal, KS

(620) 629-6291

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

18

Certified beds

Average residents

6

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1987-07-31

CMS approved date

Coverage

Medicare

Participation flags

Changed ownership

No

Within the last 12 months

Family council

No

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

3.15

Registered nurse staffing · state 0.72 · national 0.68

LPN hours / resident day

1.03

Licensed practical nurse staffing · state 0.67 · national 0.87

Aide hours / resident day

3.68

Nurse aide staffing · state 2.69 · national 2.35

Total nurse hours

7.85

All reported nurse hours · state 4.07 · national 3.89

Licensed hours

4.18

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

7.93

Weekend nurse staffing · state 3.58 · national 3.43

Weekend RN hours

2.99

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

3.33

CMS adjusted RN staffing hours

Adjusted total hours

8.29

CMS adjusted total nurse staffing hours

Case-mix index

1.30

Higher values indicate more complex resident acuity

RN turnover

0%

Annual RN turnover

Total nurse turnover

0%

Annual nurse turnover

SNF VBP

Value-based purchasing

Program rank

1,102

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

Performance score

59.91

Composite VBP score used to determine payment impact.

Payment multiplier

1.0151

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.58

Baseline 19.51% · Performance 19.31% · Measure score 4.58 · Achievement 4.58 · Improvement 0.30

Healthcare-associated infections

7.40

Baseline 5.12% · Performance 5.62% · Measure score 7.40 · Achievement 7.40 · Improvement 0

Total nurse turnover

Not reported

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

Adjusted total nurse staffing

Not reported

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

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	12.13%	10.72% 1.4 pts worse	No Different than the National Rate · Eligible stays 158 · Observed rate 10.76% · Lower 95% interval 8.92%
Discharge to community	65.79%	50.57% 15.2 pts better	Better than the National Rate · Eligible stays 141 · Observed rate 76.6% · Lower 95% interval 59.88%
Medicare spending per beneficiary	0.59	1.02 0.4 pts better
Drug regimen review with follow-up	78.9%	95.27% 16.4 pts worse	Numerator 86 · Denominator 109
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 109
Discharge self-care score	66.34%	53.69% 12.7 pts better	Numerator 67 · Denominator 101
Discharge mobility score	14.85%	50.94% 36.1 pts worse	Numerator 15 · Denominator 101
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 109 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	5.62%	7.12% 1.5 pts better	No Different than the National Rate · Eligible stays 92 · Observed rate 1.09% · Lower 95% interval 2.5%
Staff COVID-19 vaccination coverage	3.45%	8.2% 4.7 pts worse	Numerator 14 · Denominator 406
Staff flu vaccination coverage	91.86%	42% 49.9 pts better	Numerator 485 · Denominator 528
Discharge function score	19.8%	56.45% 36.7 pts worse	Numerator 20 · Denominator 101
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Transfer of health information to patient	98.92%	96.28% 2.6 pts better	Numerator 92 · Denominator 93
Resident COVID-19 vaccinations up to date	72.41%	25.2% 47.2 pts better	Numerator 42 · Denominator 58

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	98.2%	75.6% 22.6 pts better	81.7% 16.5 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.4% · Q3 98.0% · Q4 95.1% · 4Q avg 98.2%
Percentage of short-stay residents who had an outpatient emergency department visit	9.3%	11.7% 2.4 pts better	12.0% 2.7 pts better	Short Stay · 20240701-20250630 · Adjusted 9.3% · Observed 8.2% · Expected 9.8% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	2.2% 2.2 pts better	1.6% 1.6 pts better	Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	100.0%	73.5% 26.5 pts better	79.7% 20.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	20.4%	23.0% 2.6 pts better	23.9% 3.5 pts better	Short Stay · 20240701-20250630 · Adjusted 20.4% · Observed 14.3% · Expected 16.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-06-12 · Fire 2024-06-12

7 health deficiencies

Top issue: Infection Control (2 deficiencies)

8 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2022-06-08 · Fire 2022-06-08

0 health deficiencies

No concentrated health issue counts in this cycle.

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2019-09-25 · Fire 2019-09-25

1 health deficiencies

Top issue: Administration (1 deficiency)

6 fire-safety deficiencies

Top issue: Emergency Preparedness (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-06-12

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2024-07-26

F · Potential for more than minimal harm 2024-06-12

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-07-26

E · Potential for more than minimal harm 2024-06-12

E30 · Emergency Preparedness Deficiencies

Fire Safety

List the names and contact information of those in the facility.

Corrected 2024-07-26

E · Potential for more than minimal harm 2024-06-12

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-07-26

E · Potential for more than minimal harm 2024-06-12

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-07-26

E · Potential for more than minimal harm 2024-06-12

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-07-26

E · Potential for more than minimal harm 2024-06-12

K355 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-07-26

E · Potential for more than minimal harm 2024-06-12

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-07-26

F · Potential for more than minimal harm 2022-06-08

K908 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.

Corrected 2022-07-06

D · Potential for more than minimal harm 2022-06-08

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 2022-07-20

F · Potential for more than minimal harm 2019-09-25

K346 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Corrected 2018-02-01

F · Potential for more than minimal harm 2019-09-25

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2018-02-01

F · Potential for more than minimal harm 2019-09-25

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2018-01-22

D · Potential for more than minimal harm 2019-09-25

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2018-01-12

C · Minimal harm 2019-09-25

E31 · Emergency Preparedness Deficiencies

Fire Safety

Provide emergency officials' contact information.

Corrected 2018-02-01

C · Minimal harm 2019-09-25

E36 · Emergency Preparedness Deficiencies

Fire Safety

Establish emergency prep training and testing.

Corrected 2018-01-23

Inspection history

Recent health citations

F · Potential for more than minimal harm 2024-06-12

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 2024-07-17

F · Potential for more than minimal harm 2024-06-12

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2024-07-17

F · Potential for more than minimal harm 2024-06-12

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 2024-07-17

F · Potential for more than minimal harm 2024-06-12

F947 · Nursing and Physician Services Deficiencies

Health

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected 2024-07-17

D · Potential for more than minimal harm 2024-06-12

F636 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Corrected 2024-07-17

D · Potential for more than minimal harm 2024-06-12

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-07-17

D · Potential for more than minimal harm 2024-06-12

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2024-07-17

F · Potential for more than minimal harm 2019-09-25

F868 · Administration Deficiencies

Health

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Corrected 2019-10-07

Penalties and ownership

What sits behind the stars

Ownership

Cain, Sandra

W-2 Managing Employee · Individual

0% 1 facilities 2021-05-01

Cowan, Mark

Corporate Officer · Individual

0% 1 facilities 2015-05-01

Cowan, Mark

W-2 Managing Employee · Individual

0% 1 facilities 2015-05-01

Knudsen, Dennis