Cycle 1
Health 2024-04-04 · Fire 2024-04-04
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Wichita, KS
Via Christi Village Ridge
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
3636 North Ridge Rd Bldg 400, Wichita, KS
(316) 462-7502
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
80
Certified beds
Average residents
71
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ascension Living
Operator or chain grouping
Approved since
2013-09-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 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
1.02
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.28
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
2.07
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
0.68
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.04
CMS adjusted RN staffing hours
Adjusted total hours
4.35
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,035
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.16
Composite VBP score used to determine payment impact.
Payment multiplier
1.0066
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.15
Baseline 22.11% · Performance 19.74% · Measure score 4.15 · Achievement 3.64 · Improvement 4.15
Healthcare-associated infections
8.11
Baseline 6.60% · Performance 5.41% · Measure score 8.11 · Achievement 8.11 · Improvement 6.91
Total nurse turnover
4.33
Baseline 50.70% · Performance 46.00% · Measure score 4.33 · Achievement 4.33 · Improvement 1.32
Adjusted total nurse staffing
4.28
Baseline 3.81 hours · Performance 4.29 hours · Measure score 4.28 · Achievement 4.28 · Improvement 1.96
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.54% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 441 · Observed rate 11.56% · Lower 95% interval 9.52% |
| Discharge to community | 62.66% |
50.57%
12.1 pts better
|
Better than the National Rate · Eligible stays 409 · Observed rate 60.15% · Lower 95% interval 58.33% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 96.23% |
95.27%
1 pts better
|
Numerator 230 · Denominator 239 |
| Falls with major injury | 0.84% |
0.77%
0.1 pts worse
|
Numerator 2 · Denominator 239 |
| Discharge self-care score | 26.13% |
53.69%
27.6 pts worse
|
Numerator 52 · Denominator 199 |
| Discharge mobility score | 33.67% |
50.94%
17.3 pts worse
|
Numerator 67 · Denominator 199 |
| Pressure ulcers or injuries, new or worsened | 2.09% |
2.29%
0.2 pts better
|
Numerator 5 · Denominator 239 · Adjusted rate 2.63% |
| Healthcare-associated infections requiring hospitalization | 5.41% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 252 · Observed rate 3.57% · Lower 95% interval 3.61% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 130 |
| Staff flu vaccination coverage | 60.62% |
42%
18.6 pts better
|
Numerator 97 · Denominator 160 |
| Discharge function score | 31.16% |
56.45%
25.3 pts worse
|
Numerator 62 · Denominator 199 |
| Transfer of health information to provider | 96.51% |
95.95%
0.6 pts better
|
Numerator 83 · Denominator 86 |
| Transfer of health information to patient | 96.64% |
96.28%
0.4 pts better
|
Numerator 115 · Denominator 119 |
| Resident COVID-19 vaccinations up to date | 24.63% |
25.2%
0.6 pts worse
|
Numerator 33 · Denominator 134 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.8
0.9 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
2.2
1.5 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
91.8%
7 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.7% · Q4 97.4% · 4Q avg 98.8% |
| 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 4.4% · Q2 4.7% · Q3 9.3% · Q4 10.5% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
5.6%
3.6 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.5% · Q3 5.6% · Q4 0.0% · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
5.0%
2.2 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 8.0% · Q4 0.0% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.3% |
23.2%
9.9 pts better
|
19.6%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 13.8% · Q3 7.4% · Q4 8.7% · 4Q avg 13.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.1% |
19.8%
12.7 pts better
|
16.7%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 4.8% · 4Q avg 7.1% · 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 | 32.3% |
18.4%
13.9 pts worse
|
16.3%
16 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 32.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.0% |
18.8%
1.2 pts worse
|
14.9%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 20.8% · Q3 24.0% · 4Q avg 20.0% · 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 | 0.6% |
3.1%
2.5 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.7% |
23.2%
7.5 pts worse
|
19.8%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.3% · Q2 37.7% · Q3 25.6% · Q4 29.8% · 4Q avg 30.7% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
4.6%
About the same
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 5.4% · Q3 4.0% · Q4 0.0% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
75.6%
21.4 pts better
|
81.7%
15.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.9% · Q2 98.2% · Q3 97.6% · Q4 97.4% · 4Q avg 97.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.1% |
11.7%
1.6 pts better
|
12.0%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.1% · Observed 9.3% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.1% |
2.2%
2.1 pts better
|
1.6%
1.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.1% |
73.5%
22.6 pts better
|
79.7%
16.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.1% |
23.0%
0.9 pts better
|
23.9%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.1% · Observed 20.4% · Expected 21.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-04-11 · Fire 2022-04-11
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
24 fire-safety deficiencies
Top issue: Emergency Preparedness (9 deficiencies)
Cycle 3
Health 2020-10-08 · Fire 2020-10-08
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-04
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-05-30
F · Potential for more than minimal harm
2024-04-04
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-05-30
F · Potential for more than minimal harm
2024-04-04
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-05-30
F · Potential for more than minimal harm
2024-04-04
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 2024-06-10
F · Potential for more than minimal harm
2024-04-04
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-05-30
F · Potential for more than minimal harm
2024-04-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-02
F · Potential for more than minimal harm
2024-04-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-14
F · Potential for more than minimal harm
2024-04-04
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-10
F · Potential for more than minimal harm
2024-04-04
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-06-10
E · Potential for more than minimal harm
2024-04-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-10
F · Potential for more than minimal harm
2022-04-11
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-04-07
F · Potential for more than minimal harm
2022-04-11
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2022-04-07
F · Potential for more than minimal harm
2022-04-11
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2022-04-07
F · Potential for more than minimal harm
2022-04-11
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2022-04-07
F · Potential for more than minimal harm
2022-04-11
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2022-04-07
F · Potential for more than minimal harm
2022-04-11
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2022-04-07
F · Potential for more than minimal harm
2022-04-11
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-04-07
F · Potential for more than minimal harm
2022-04-11
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-04-07
F · Potential for more than minimal harm
2022-04-11
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-04-07
F · Potential for more than minimal harm
2022-04-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-04-07
F · Potential for more than minimal harm
2022-04-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-04-07
F · Potential for more than minimal harm
2022-04-11
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2022-04-07
F · Potential for more than minimal harm
2022-04-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-04-07
F · Potential for more than minimal harm
2022-04-11
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-04-07
F · Potential for more than minimal harm
2022-04-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-04-07
F · Potential for more than minimal harm
2022-04-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-04-07
F · Potential for more than minimal harm
2022-04-11
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-04-07
F · Potential for more than minimal harm
2022-04-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-04-07
F · Potential for more than minimal harm
2022-04-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-04-07
F · Potential for more than minimal harm
2022-04-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-04-07
F · Potential for more than minimal harm
2022-04-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-04-07
E · Potential for more than minimal harm
2022-04-11
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 2022-04-07
E · Potential for more than minimal harm
2022-04-11
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 2022-04-07
E · Potential for more than minimal harm
2022-04-11
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2022-04-07
F · Potential for more than minimal harm
2020-10-08
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2020-12-30
F · Potential for more than minimal harm
2020-10-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-12-30
F · Potential for more than minimal harm
2020-10-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-12-30
F · Potential for more than minimal harm
2020-10-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-12-30
E · Potential for more than minimal harm
2020-10-08
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2020-12-30
E · Potential for more than minimal harm
2020-10-08
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 2020-12-30
E · Potential for more than minimal harm
2020-10-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-12-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-23
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-10-22
G · Actual harm
2024-06-25
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 2024-07-15
E · Potential for more than minimal harm
2024-04-04
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-27
E · Potential for more than minimal harm
2024-04-04
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 2024-04-27
E · Potential for more than minimal harm
2024-04-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-27
E · Potential for more than minimal harm
2024-04-04
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-04-27
D · Potential for more than minimal harm
2024-04-04
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 2024-04-27
D · Potential for more than minimal harm
2024-04-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-27
D · Potential for more than minimal harm
2022-04-11
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 2022-05-18
D · Potential for more than minimal harm
2022-04-11
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 2022-05-18
D · Potential for more than minimal harm
2022-04-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-05-18
D · Potential for more than minimal harm
2022-04-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-05-18
D · Potential for more than minimal harm
2022-04-11
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-05-18
D · Potential for more than minimal harm
2022-04-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-18
D · Potential for more than minimal harm
2020-10-08
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2020-11-08
Penalties and ownership
What sits behind the stars
Ownership
Ascension Health Senior Care
5% Or Greater Direct Ownership Interest · Organization
Loyd, Michail
Operational/Managerial Control · Individual
Mccue, Tamara
Operational/Managerial Control · Individual
Musgrave, Lisa
Corporate Director · Individual
Shadbolt, Erin
Corporate Officer · Individual
Smoot, Kenneth
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Azria Health Wichita
Wichita, KS
2-star overall rating with 2-star inspections with 15 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Wichita Presbyterian Manor
Wichita, KS
4-star overall rating with 4-star inspections with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Lakepoint Wichita, LLC
Wichita, KS
2-star overall rating with 2-star inspections with $18,342 in total fines with 12 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
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