Cycle 1
Health 2025-01-23 · Fire 2025-01-23
3 health deficiencies
Top issue: Infection Control (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Dodge City, KS
Trinity Manor
4-star overall rating with 4-star inspections with $29,773 in total fines with 3 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
510 W Frontview Street, Dodge City, KS
(620) 227-8551
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
46
Certified beds
Average residents
39
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Frontline Management
Operator or chain grouping
Approved since
1996-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
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
0.91
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.21
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.22
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.34
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.12
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.95
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.87
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
1.00
CMS adjusted RN staffing hours
Adjusted total hours
3.64
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,622
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.69
Composite VBP score used to determine payment impact.
Payment multiplier
1.0025
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.53
Baseline 19.21% · Performance 18.87% · Measure score 5.53 · Achievement 5.53 · Improvement 1.06
Healthcare-associated infections
4.10
Baseline 7.01% · Performance 6.61% · Measure score 4.10 · Achievement 4.10 · Improvement 1.48
Total nurse turnover
4.10
Baseline 48.84% · Performance 46.94% · Measure score 4.10 · Achievement 4.10 · Improvement 0.29
Adjusted total nurse staffing
5.76
Baseline 3.83 hours · Performance 4.72 hours · Measure score 5.76 · Achievement 5.76 · Improvement 4.03
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.02% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 69 · Observed rate 11.59% · Lower 95% interval 7.54% |
| Discharge to community | 59.56% |
50.57%
9 pts better
|
No Different than the National Rate · Eligible stays 62 · Observed rate 58.06% · Lower 95% interval 48.85% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 41 · Denominator 41 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 41 |
| Discharge self-care score | 37.04% |
53.69%
16.6 pts worse
|
Numerator 10 · Denominator 27 |
| Discharge mobility score | 14.81% |
50.94%
36.1 pts worse
|
Numerator 4 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 41 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.61% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 34 · Observed rate 2.94% · Lower 95% interval 3.41% |
| Staff COVID-19 vaccination coverage | 11.76% |
8.2%
3.6 pts better
|
Numerator 8 · Denominator 68 |
| Staff flu vaccination coverage | 79.41% |
42%
37.4 pts better
|
Numerator 54 · Denominator 68 |
| Discharge function score | 55.56% |
56.45%
0.9 pts worse
|
Numerator 15 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 90.48% |
96.28%
5.8 pts worse
|
Numerator 19 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 31.82% |
25.2%
6.6 pts better
|
Numerator 7 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.8
0.6 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
2.2
0.2 pts better
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.9 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.0% |
91.8%
2.2 pts better
|
93.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 94.4% · Q3 90.9% · Q4 93.5% · 4Q avg 94.0% |
| 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 | 4.5% |
4.4%
0.1 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 5.6% · Q3 3.0% · Q4 3.2% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.6%
5.6 pts better
|
11.4%
11.4 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 who lose too much weight | 6.3% |
5.0%
1.3 pts worse
|
5.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 5.7% · Q3 6.7% · Q4 3.6% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.0% |
23.2%
1.2 pts better
|
19.6%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 25.0% · Q3 21.9% · Q4 20.0% · 4Q avg 22.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.8% |
19.8%
About the same
|
16.7%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 16.0% · Q3 19.0% · Q4 21.7% · 4Q avg 19.8% · 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 | 28.8% |
18.4%
10.4 pts worse
|
16.3%
12.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.8% |
18.8%
2 pts worse
|
14.9%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 23.5% · Q3 20.0% · Q4 25.0% · 4Q avg 20.8% · 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 | 27.5% |
23.2%
4.3 pts worse
|
19.8%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 27.2% · Q3 26.1% · Q4 31.1% · 4Q avg 27.5% |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
4.6%
2.4 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 0.0% · Q3 0.0% · Q4 4.8% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.6% |
75.6%
15 pts better
|
81.7%
8.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.3% · Q2 93.5% · Q3 96.8% · Q4 82.4% · 4Q avg 90.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 31.0% |
11.7%
19.3 pts worse
|
12.0%
19 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.0% · Observed 33.3% · Expected 12.0% · 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% · 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 | 84.8% |
73.5%
11.3 pts better
|
79.7%
5.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.3% |
23.0%
3.3 pts worse
|
23.9%
2.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.3% · Observed 30.6% · Expected 27.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-09 · Fire 2023-02-09
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
6 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2021-07-15 · Fire 2021-07-15
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-23
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-02-15
F · Potential for more than minimal harm
2025-01-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-15
F · Potential for more than minimal harm
2025-01-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-03
E · Potential for more than minimal harm
2025-01-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-15
E · Potential for more than minimal harm
2025-01-23
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-20
E · Potential for more than minimal harm
2025-01-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-15
E · Potential for more than minimal harm
2025-01-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-02-20
E · Potential for more than minimal harm
2025-01-23
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-02-20
E · Potential for more than minimal harm
2025-01-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-03
F · Potential for more than minimal harm
2023-02-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-29
F · Potential for more than minimal harm
2023-02-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-29
F · Potential for more than minimal harm
2023-02-09
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-03-29
E · Potential for more than minimal harm
2023-02-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-29
D · Potential for more than minimal harm
2023-02-09
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 2023-03-29
D · Potential for more than minimal harm
2023-02-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-03-29
E · Potential for more than minimal harm
2021-07-15
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2021-08-26
D · Potential for more than minimal harm
2021-07-15
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 2021-08-26
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-01-23
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 2025-02-28
F · Potential for more than minimal harm
2025-01-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-23
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-02-28
J · Immediate jeopardy
2024-07-15
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 2024-07-03
J · Immediate jeopardy
2024-02-08
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 2024-02-05
F · Potential for more than minimal harm
2023-02-09
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 2023-02-28
D · Potential for more than minimal harm
2023-02-09
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-02-28
D · Potential for more than minimal harm
2023-02-09
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-02-28
F · Potential for more than minimal harm
2021-07-15
F801 · Nutrition and Dietary Deficiencies
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.
Corrected 2021-08-24
F · Potential for more than minimal harm
2021-07-15
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 2021-08-24
D · Potential for more than minimal harm
2021-07-15
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2021-08-24
D · Potential for more than minimal harm
2021-07-15
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2021-08-24
D · Potential for more than minimal harm
2021-07-15
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 2021-08-24
D · Potential for more than minimal harm
2021-07-15
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-08-24
D · Potential for more than minimal harm
2021-07-15
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 2021-08-24
Penalties and ownership
What sits behind the stars
$17,124
2024-07-15
Fine
Fine · fine $17,124
Fine
$12,649
2024-02-08
Fine
Fine · fine $12,649
Fine
Ownership
Trinity Manor Propco LLC
5% Or Greater Direct Ownership Interest · Organization
Able, Sara
Operational/Managerial Control · Individual
Baker, Adam
Operational/Managerial Control · Individual
Eisel, Rhonda
Operational/Managerial Control · Individual
Elliot, Stacia
Operational/Managerial Control · Individual
Frontier Management Inc
Operational/Managerial Control · Organization
Jones, Robert
Operational/Managerial Control · Individual
Kendig, Debbie
Operational/Managerial Control · Individual
Kerns, Cetra
Operational/Managerial Control · Individual
Lampe, Tammy
Operational/Managerial Control · Individual
Mazza, Lisa
Operational/Managerial Control · Individual
Newton, Michelle
Operational/Managerial Control · Individual
Ong, Edison
Operational/Managerial Control · Individual
Orback, Heather
Operational/Managerial Control · Individual
Ordelheide, Colleen
5% Or Greater Indirect Ownership Interest · Individual
Salas, Cherise
Operational/Managerial Control · Individual
Saracino, Kelly
Operational/Managerial Control · Individual
Schauliege, Tanner
Operational/Managerial Control · Individual
Scott, Angela
Operational/Managerial Control · Individual
Trinity Manor Associates LLC
5% Or Greater Indirect Ownership Interest · Organization
Trinity Manor Propco LLC
5% Or Greater Indirect Ownership Interest · Organization
Trotter, Roger
Operational/Managerial Control · Individual
Veluscek, Steven
5% Or Greater Indirect Ownership Interest · Individual
Veluscek, Steven
Corporate Officer · Individual
Wheeler, Terry
5% Or Greater Indirect Ownership Interest · Individual
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#3
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