Cycle 1
Health 2024-08-21 · Fire 2024-08-21
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Wellsville, KS
Wellsville Manor
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
304 W 7th St, Wellsville, KS
(785) 883-4101
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
51
Certified beds
Average residents
47
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-04-15
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
0.73
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.23
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
3.89
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.86
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
0.97
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.44
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.59
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.18
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.78
CMS adjusted RN staffing hours
Adjusted total hours
5.19
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,797
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.67
Composite VBP score used to determine payment impact.
Payment multiplier
0.9839
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.13
Baseline 19.43% · Performance 20.44% · Measure score 2.13 · Achievement 2.13 · Improvement 0
Healthcare-associated infections
0.92
Baseline 5.47% · Performance 7.56% · Measure score 0.92 · Achievement 0.92 · Improvement 0
Total nurse turnover
1.55
Baseline 64.52% · Performance 57.33% · Measure score 1.55 · Achievement 1.55 · Improvement 1.31
Adjusted total nurse staffing
5.67
Baseline 4.20 hours · Performance 4.69 hours · Measure score 5.67 · Achievement 5.67 · Improvement 2.59
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.9% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 70 · Observed rate 5.71% · Lower 95% interval 6.81% |
| Discharge to community | 55.24% |
50.57%
4.7 pts better
|
No Different than the National Rate · Eligible stays 54 · Observed rate 57.41% · Lower 95% interval 44.89% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 49 · Denominator 49 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 49 |
| Discharge self-care score | 47.37% |
53.69%
6.3 pts worse
|
Numerator 18 · Denominator 38 |
| Discharge mobility score | 42.11% |
50.94%
8.8 pts worse
|
Numerator 16 · Denominator 38 |
| Pressure ulcers or injuries, new or worsened | 6.12% |
2.29%
3.8 pts worse
|
Numerator 3 · Denominator 49 · Adjusted rate 6.47% |
| Healthcare-associated infections requiring hospitalization | 7.56% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 7.5% · Lower 95% interval 3.91% |
| Staff COVID-19 vaccination coverage | 2.52% |
8.2%
5.7 pts worse
|
Numerator 4 · Denominator 159 |
| Staff flu vaccination coverage | 15.38% |
42%
26.6 pts worse
|
Numerator 26 · Denominator 169 |
| Discharge function score | 28.95% |
56.45%
27.5 pts worse
|
Numerator 11 · Denominator 38 |
| 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 | 95.24% |
96.28%
1 pts worse
|
Numerator 20 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 40% |
25.2%
14.8 pts better
|
Numerator 10 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.8
0.2 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
2.2
1.1 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.6% |
91.8%
4.2 pts worse
|
93.4%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 94.7% · Q2 87.5% · Q3 86.4% · Q4 83.0% · 4Q avg 87.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.0% |
95.5%
2.5 pts worse
|
95.5%
2.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
4.4%
1.4 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 2.5% · Q3 2.3% · Q4 2.1% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
5.6%
3.7 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.8% · Q4 2.2% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 3.2% |
5.0%
1.8 pts better
|
5.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 5.6% · Q3 0.0% · Q4 2.3% · 4Q avg 3.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.1% |
23.2%
13.1 pts better
|
19.6%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 36.1% · Q2 5.3% · Q3 0.0% · Q4 2.3% · 4Q avg 10.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.9% |
19.8%
9.9 pts better
|
16.7%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 10.0% · Q3 11.1% · Q4 8.3% · 4Q avg 9.9% · 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 | 17.2% |
18.4%
1.2 pts better
|
16.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 13.8% · Q3 19.7% · Q4 24.1% · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.6% |
18.8%
2.2 pts better
|
14.9%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 11.1% · Q3 19.4% · Q4 20.0% · 4Q avg 16.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.2% |
1.8%
1.4 pts worse
|
1.0%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 4.5% · Q3 2.0% · Q4 3.0% · 4Q avg 3.2% · 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 | 18.6% |
23.2%
4.6 pts better
|
19.8%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.6% · Q2 21.7% · Q3 25.6% · Q4 14.8% · 4Q avg 18.6% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
4.6%
0.2 pts worse
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 7.1% · Q4 7.7% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 50.0% |
75.6%
25.6 pts worse
|
81.7%
31.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 47.2% · Q2 42.9% · Q3 50.0% · Q4 63.6% · 4Q avg 50.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.7% |
11.7%
1 pts better
|
12.0%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.7% · Observed 9.8% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.6% |
2.2%
3.4 pts worse
|
1.6%
4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.0% · Q3 4.8% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 31.0% |
73.5%
42.5 pts worse
|
79.7%
48.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 31.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.2% |
23.0%
0.8 pts better
|
23.9%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.2% · Observed 19.5% · Expected 21.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-30 · Fire 2022-11-30
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2021-05-24 · Fire 2021-05-24
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
11 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-21
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-11-21
F · Potential for more than minimal harm
2024-08-21
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-10-08
F · Potential for more than minimal harm
2024-08-21
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-11-21
F · Potential for more than minimal harm
2024-08-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-05
F · Potential for more than minimal harm
2024-08-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-21
F · Potential for more than minimal harm
2024-08-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-21
F · Potential for more than minimal harm
2024-08-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-21
F · Potential for more than minimal harm
2024-08-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-11-21
F · Potential for more than minimal harm
2024-08-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-21
F · Potential for more than minimal harm
2024-08-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-08
F · Potential for more than minimal harm
2024-08-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-21
F · Potential for more than minimal harm
2024-08-21
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-11-21
F · Potential for more than minimal harm
2022-11-30
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-02-27
F · Potential for more than minimal harm
2022-11-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-27
F · Potential for more than minimal harm
2022-11-30
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2023-02-27
F · Potential for more than minimal harm
2022-11-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-27
E · Potential for more than minimal harm
2022-11-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-02-27
E · Potential for more than minimal harm
2022-11-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-02-27
F · Potential for more than minimal harm
2021-05-24
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2021-09-08
F · Potential for more than minimal harm
2021-05-24
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 2021-09-08
F · Potential for more than minimal harm
2021-05-24
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2021-09-08
F · Potential for more than minimal harm
2021-05-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-09-08
F · Potential for more than minimal harm
2021-05-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-09-08
F · Potential for more than minimal harm
2021-05-24
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 2021-09-08
F · Potential for more than minimal harm
2021-05-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-09-08
F · Potential for more than minimal harm
2021-05-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-09-08
E · Potential for more than minimal harm
2021-05-24
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-09-08
E · Potential for more than minimal harm
2021-05-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-09-08
E · Potential for more than minimal harm
2021-05-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-09-08
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-08-21
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 2024-09-16
E · Potential for more than minimal harm
2024-08-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-21
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-16
F · Potential for more than minimal harm
2022-11-30
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 2022-12-15
E · Potential for more than minimal harm
2022-11-30
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-12-15
D · Potential for more than minimal harm
2022-11-30
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 2022-12-15
D · Potential for more than minimal harm
2022-11-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-15
D · Potential for more than minimal harm
2021-05-24
F690 · Quality of Life and Care Deficiencies
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 2021-06-15
Penalties and ownership
What sits behind the stars
Ownership
Averill, Scott
5% Or Greater Direct Ownership Interest · Individual
Averill, Scott
Corporate Officer · Individual
Averill, Scott
Contracted Managing Employee · Individual
Hoback, Denise
Corporate Officer · Individual
Hoback, Denise
Contracted Managing Employee · Individual
Joya Living & Healthcare Inc
Operational/Managerial Control · Organization
Lee, Tara
W-2 Managing Employee · Individual
Mccoy, Jillian
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
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5-star overall rating with 4-star inspections with 10 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#2
Meadowbrook Rehabilitation Hospital
Gardner, KS
1-star overall rating with 1-star inspections with $64,629 in total fines with 14 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Rock Creek Of Ottawa
Ottawa, KS
2-star overall rating with 2-star inspections with 16 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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