Cycle 1
Health 2024-09-18 · Fire 2024-09-18
8 health deficiencies
Top issue: Infection Control (3 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Westmoreland, KS
Westy Community Care Home
2-star overall rating with 2-star inspections with $19,406 in total fines with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
105 N Highway 99, Westmoreland, KS
(785) 457-2801
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
40
Certified beds
Average residents
30
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2003-12-01
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
0.79
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.33
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.97
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.10
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
3.73
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.66
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.95
CMS adjusted RN staffing hours
Adjusted total hours
4.92
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,211
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.62
Composite VBP score used to determine payment impact.
Payment multiplier
0.9878
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Baseline 65.00% · Performance 67.35% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
6.72
Baseline 5.09 hours · Performance 4.99 hours · Measure score 6.72 · Achievement 6.72 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.11% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 27 · Observed rate 11.11% · Lower 95% interval 7.45% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 18 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 13.11% |
8.2%
4.9 pts better
|
Numerator 8 · Denominator 61 |
| Staff flu vaccination coverage | 20.24% |
42%
21.8 pts worse
|
Numerator 17 · Denominator 84 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.8
0.1 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
2.2
0.3 pts better
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
91.8%
5.6 pts better
|
93.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 96.6% · Q4 93.5% · 4Q avg 97.4% |
| 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 | 2.6% |
4.4%
1.8 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.4% · Q4 6.5% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
5.6%
4.5 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 6.7% |
5.0%
1.7 pts worse
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 4.5% · Q3 8.7% · Q4 8.3% · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.6% |
23.2%
0.6 pts better
|
19.6%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 16.7% · Q3 29.2% · Q4 24.0% · 4Q avg 22.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 34.7% |
19.8%
14.9 pts worse
|
16.7%
18 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 36.4% · 4Q avg 34.7% · 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 | 20.0% |
18.4%
1.6 pts worse
|
16.3%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q3 32.5% · 4Q avg 20.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.7% |
18.8%
7.9 pts worse
|
14.9%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 16.7% · Q3 33.3% · Q4 40.9% · 4Q avg 26.7% · 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 | 0.9% |
3.1%
2.2 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.3% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.9% |
23.2%
2.7 pts worse
|
19.8%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.1% · Q2 18.1% · Q3 35.9% · Q4 27.0% · 4Q avg 25.9% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
4.6%
0.9 pts worse
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 11.7% · Q3 4.6% · Q4 6.1% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.1% |
75.6%
9.5 pts better
|
81.7%
3.4 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 85.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.5% |
11.7%
2.2 pts better
|
12.0%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.5% · Observed 9.1% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 8.0% |
2.2%
5.8 pts worse
|
1.6%
6.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 8.0% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.9% |
23.0%
4.9 pts worse
|
23.9%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.9% · Observed 27.3% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-28 · Fire 2023-03-28
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-09-08 · Fire 2021-09-08
6 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
16 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-18
F · Potential for more than minimal harm
2023-03-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-04
F · Potential for more than minimal harm
2023-03-28
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-05-04
F · Potential for more than minimal harm
2023-03-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-04
F · Potential for more than minimal harm
2023-03-28
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2023-05-04
E · Potential for more than minimal harm
2023-03-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-04
E · Potential for more than minimal harm
2023-03-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-04
F · Potential for more than minimal harm
2021-09-08
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2021-10-20
F · Potential for more than minimal harm
2021-09-08
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2021-10-20
F · Potential for more than minimal harm
2021-09-08
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2021-10-20
F · Potential for more than minimal harm
2021-09-08
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2021-10-20
F · Potential for more than minimal harm
2021-09-08
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2021-10-20
F · Potential for more than minimal harm
2021-09-08
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2021-10-20
F · Potential for more than minimal harm
2021-09-08
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 2021-10-20
F · Potential for more than minimal harm
2021-09-08
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 2021-10-20
F · Potential for more than minimal harm
2021-09-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-10-20
F · Potential for more than minimal harm
2021-09-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-10-20
F · Potential for more than minimal harm
2021-09-08
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2021-10-20
F · Potential for more than minimal harm
2021-09-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-10-20
F · Potential for more than minimal harm
2021-09-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-10-20
F · Potential for more than minimal harm
2021-09-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-10-20
F · Potential for more than minimal harm
2021-09-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-10-20
E · Potential for more than minimal harm
2021-09-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-10-20
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-09-18
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 2024-09-27
F · Potential for more than minimal harm
2024-09-18
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 2024-09-27
F · Potential for more than minimal harm
2024-09-18
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-09-27
E · Potential for more than minimal harm
2024-09-18
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-09-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-09-18
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 2024-09-27
D · Potential for more than minimal harm
2024-09-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-09-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-27
G · Actual harm
2024-02-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-12
D · Potential for more than minimal harm
2024-02-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-12
J · Immediate jeopardy
2024-01-31
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 2024-01-25
D · Potential for more than minimal harm
2023-10-10
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 2023-10-25
G · Actual harm
2023-03-28
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 2023-05-19
F · Potential for more than minimal harm
2023-03-28
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-04-19
D · Potential for more than minimal harm
2023-03-28
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-03-28
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-03-28
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 2023-04-19
D · Potential for more than minimal harm
2023-03-28
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-04-19
D · Potential for more than minimal harm
2023-03-28
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-03-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-19
D · Potential for more than minimal harm
2023-03-28
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-04-19
D · Potential for more than minimal harm
2023-03-28
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 2023-05-19
E · Potential for more than minimal harm
2021-09-08
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 2021-09-10
D · Potential for more than minimal harm
2021-09-08
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2021-09-10
Penalties and ownership
What sits behind the stars
$11,213
2024-02-26
Fine
Fine · fine $11,213
Fine
$8,193
2024-01-31
Fine
Fine · fine $8,193
Fine
$0
2023-03-28
Payment Denial
Payment Denial · denial start 2023-05-01 · 18 days
18 day denial
Ownership
Rifford, Michelle
5% Or Greater Direct Ownership Interest · Individual
Campbell, Michelle
Corporate Officer · Individual
Ebert, Clara
Corporate Officer · Individual
Fouts, Willa
Corporate Officer · Individual
Frank, Charles
Corporate Officer · Individual
Heptig, Robert
Corporate Officer · Individual
Rifford, Michelle
W-2 Managing Employee · Individual
Stalder, Robert
Corporate Officer · Individual
Strifler, Sharon
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Good Samaritan Society - Valley Vista
Wamego, KS
4-star overall rating with 3-star inspections with $26,525 in total fines with 11 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Meadowlark Hills
Manhattan, KS
5-star overall rating with 4-star inspections with $8,278 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Onaga Operator, LLC
Onaga, KS
2-star overall rating with 2-star inspections with abuse icon flag with $26,429 in total fines with 8 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
Jump out