A
MOUNDRIDGE MANOR
83/100 score
0.73 hrs RN staffing
3 deficiencies
PINE VILLAGE
86 TWENTY-SECOND AVENUE, MOUNDRIDGE, KS 67107
C
Facility Assessment
This facility staffs below 0.55 RN hours per resident day — the level the 2024 federal rule, repealed in February 2026, would have required.
Below the repealed 0.55 hr RN benchmark — average inspection record.
Quality Breakdown
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RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
|
0.52 — Below the repealed 0.55 hr benchmark |
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why |
|
|
Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
|
Total
13
Outstanding
0
Actual harm or worse (G–L)
0
|
|
CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
|
Quality: ★★☆☆☆ (2/5)
Staffing: ★★★★☆ (4/5)
|
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NursingHomeGrade Score
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62/100 |
Loaded into NursingHomeGrade on April 12, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
13 deficiencies found. 13 corrected. None involved actual harm.
Most recent inspection (May 6, 2025)
F
Potential harm — widespread
F0851
Status: Corrected
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Administration Deficiencies — Deficient, Provider has date of correction, corrected May 23, 2025
E
Potential harm — pattern
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected May 23, 2025
F
Potential harm — widespread
F0812
Status: Corrected
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected May 23, 2025
D
Potential harm — isolated
F0757
Status: Corrected
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected May 23, 2025
Inspection cycle 2 (August 31, 2023)
F
Potential harm — widespread
F0730
Status: Corrected
Observe each nurse aide's job performance and give regular training.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected September 15, 2023
D
Potential harm — isolated
F0758
Status: Corrected
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.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected September 15, 2023
D
Potential harm — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 15, 2023
D
Potential harm — isolated
F0661
Status: Corrected
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected September 15, 2023
Inspection cycle 3 (December 21, 2021)
D
Potential harm — isolated
F0758
Status: Corrected
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.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected January 26, 2022
D
Potential harm — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 26, 2022
D
Potential harm — isolated
F0700
Status: Corrected
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 26, 2022
D
Potential harm — isolated
F0645
Status: Corrected
PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected January 26, 2022
D
Potential harm — isolated
F0582
Status: Corrected
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected January 26, 2022
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