9 health deficiencies
Top issue: Resident Rights (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Mcpherson, KS
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
1021 Cedars Drive, Mcpherson, KS
(620) 241-0919
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
54
Certified beds
Average residents
39
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-07-10
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
RN hours / resident day
0.37
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.15
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.55
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.08
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.86
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.33
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
0.43
CMS adjusted RN staffing hours
Adjusted total hours
4.70
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
83%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
2,321
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.22
Composite VBP score used to determine payment impact.
Payment multiplier
1.0043
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.85
Baseline 20.87% · Performance 19.65% · Measure score 3.85 · Achievement 3.85 · Improvement 2.68
Healthcare-associated infections
5.53
Baseline 7.52% · Performance 6.18% · Measure score 5.53 · Achievement 5.53 · Improvement 4.79
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
5.69
Baseline 4.43 hours · Performance 4.70 hours · Measure score 5.69 · Achievement 5.69 · Improvement 1.49
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.12% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 57 · Observed rate 5.26% · Lower 95% interval 6.38% |
| Discharge to community | 64.81% |
50.57%
14.2 pts better
|
Better than the National Rate · Eligible stays 46 · Observed rate 71.74% · Lower 95% interval 54.25% |
| Medicare spending per beneficiary | 0.73 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 89.74% |
95.27%
5.5 pts worse
|
Numerator 35 · Denominator 39 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 39 |
| Discharge self-care score | 54.55% |
53.69%
0.9 pts better
|
Numerator 18 · Denominator 33 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 11 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 39 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.18% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 0% · Lower 95% interval 3.05% |
| Staff COVID-19 vaccination coverage | 0.8% |
8.2%
7.4 pts worse
|
Numerator 2 · Denominator 250 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 63.64% |
56.45%
7.2 pts better
|
Numerator 21 · Denominator 33 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 26 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | 15.15% |
25.2%
10 pts worse
|
Numerator 5 · Denominator 33 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.8
0.5 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
2.2
0.3 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.1% |
91.8%
6.7 pts worse
|
93.4%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 70.4% · Q2 77.8% · Q3 92.3% · Q4 97.1% · 4Q avg 85.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.3% |
95.5%
6.2 pts worse
|
95.5%
6.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.4% |
4.4%
About the same
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 7.4% · Q3 3.8% · Q4 2.9% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
5.6%
4.6 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.2% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
5.0%
2.3 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 9.5% · Q4 4.2% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.6% |
23.2%
1.6 pts better
|
19.6%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 28.6% · Q3 20.0% · Q4 11.5% · 4Q avg 21.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.1% |
19.8%
4.7 pts better
|
16.7%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 15.0% · 4Q avg 15.1% · 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 | 36.2% |
18.4%
17.8 pts worse
|
16.3%
19.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 36.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 34.5% |
18.8%
15.7 pts worse
|
14.9%
19.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 28.6% · Q4 36.0% · 4Q avg 34.5% · 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 | 0.0% |
3.1%
3.1 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 28.9% |
23.2%
5.7 pts worse
|
19.8%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.6% · Q2 37.4% · Q3 37.9% · Q4 6.0% · 4Q avg 28.9% |
| Percentage of long-stay residents with pressure ulcers | 7.4% |
4.6%
2.8 pts worse
|
5.1%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 6.1% · Q3 7.7% · Q4 10.2% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.7% |
75.6%
9.1 pts better
|
81.7%
3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 69.0% · Q2 78.1% · Q3 91.9% · Q4 100.0% · 4Q avg 84.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
11.7%
2.6 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 7.8% · Expected 9.6% · 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% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 62.5% |
73.5%
11 pts worse
|
79.7%
17.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 62.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.7% |
23.0%
6.7 pts worse
|
23.9%
5.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.7% · Observed 21.6% · Expected 17.3% · Used in QM five-star |
Survey summary
Top issue: Resident Rights (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Fire safety
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-05-22
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-05-22
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-22
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-22
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-22
Fire Safety
Use approved construction type or materials.
Corrected 2024-05-22
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-05-22
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-05-22
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-05-22
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 2022-11-08
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-08
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-08
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-11-08
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-04
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-11-08
Fire Safety
Meet other general requirements.
Corrected 2021-09-08
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-09-08
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 2021-09-08
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-09-08
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2021-09-08
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2021-09-08
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-08-04
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-09-08
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-09-08
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-09-08
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-09-08
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-09-08
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-09-08
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2021-09-08
Inspection history
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Not marked corrected
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Not marked corrected
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Not marked corrected
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Not marked corrected
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Not marked corrected
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Not marked corrected
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.
Not marked corrected
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Not marked corrected
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-12-15
Health
Respond appropriately to all alleged violations.
Corrected 2024-12-15
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-20
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-04-20
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-04-20
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-04-20
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 2024-04-20
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-20
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-20
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-04-20
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-20
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-04-20
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-11
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-06-15
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-06-15
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-09-15
Health
Honor each resident's preferences, choices, values and beliefs.
Corrected 2022-09-15
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 2022-09-15
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 2022-09-15
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 2022-09-15
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-09-15
Penalties and ownership
Corporate Officer · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
Nearby options
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