Fredonia Regional Hospital
A critical access hospital in Fredonia, Kansas 66736
1527 Madison, Fredonia, Kansas 66736. (620) 378-2121.
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The short answer
Record last released by CMS on Oct 20, 2026.
- Not rated CMS’s overall rating
- Not rated patient survey rating
- 1 deficiency cited in the last three years
- 32 beds
Each figure’s source sits beside it, in its section below.
What these words mean2
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
The last inspection on record was on Oct 9, 2025: a complaint inspection.
1 deficiency cited in the last three years.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
1 deficiency in 1 month of the last 36. Last cited Oct 2025. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Oct 9, 2025: complaint inspection1 deficiency
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Patient Care Policies
The inspectors’ words, 811 words
“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 49856 Based on policy review, record review, and interview the Critical Access Hospital (CAH) failed to ensure health care services were provided in accordance with updated written policy for 3 (Patient ’ s 1, 2, and 7) of 7 sampled patients. Failure to update or follow appropriate written policy places patient at risk for negative outcomes and unmet care needs. Findings Include: Review of the CAH policy titled, “CODE BLUE MANAGEMENT” last reviewed 02/03/25, showed “Code blue team roles are assigned by the House Supervisor at the beginning of the shift. This is subject to change as other staff arrives. ... The Team Leader of the code will be the most experienced Registered Nurse available. ... The electronic code blue record will be completed by the patient ’ s nurse. The House Supervisor can assist if needed. ... Code blue critiques will be distributed to all staff involved in the code blue and returned to the ER supervisor.” Patient 1 Review of Patient 1 ’ s medical record showed a 55-year-old admitted to the emergency room (ER) on 06/11/25 at 4:23 AM with a primary diagnosis of a code blue (no breathing or pulse). The record showed the code blue was ended by physician bedside order on 06/11/25 at 4:39 AM with no return of spontaneous circulation (ROSC) achieved. Patient 1 ’ s body was released to the mortuary on 06/11/25 at 5:20 AM. Patient 1 ’ s record failed to show evidence of a designated code blue team or team leader during the code blue per hospital policy. Patient 2 Review of Patient 2 ’ s medical record showed a 61-year-old admitted to the ER on 06/11/25 at 9:49 AM with a primary diagnosis of code blue. The record showed the code blue was ended with no ROSC achieved on 06/11/25 at 10:28 AM. Patient 2 ’ s body was released to the mortuary on 06/11/25 at 1:32 PM. Patient 2 ’ s medical record failed to show evidence of a designated code blue team or team leader during the code blue per hospital policy. Patient 7 Patient 7 ’ s medical record showed an 18-year-old admitted to the ER on 08/30/25 at 10:06 AM with a primary diagnosis of code blue. The record showed the code blue was ended with no ROSC achieved on 08/30/25 at 10:32 AM. Patient 7 ’ s body was released to the mortuary on 08/30/25 at 11:26 AM. Patient 7 ’ s medical record failed to show evidence of a designated code blue team or team leader during the code blue per hospital policy. During an interview on 10/08/25 at 11:45 AM, Staff H, RN, Paramedic, Director of Emergency Medical Services (EMS), stated that any code blue situations in the hospital the team leader is not always designated and could be one of the paramedics from EMS, the ER RN, or the ER physician depending on the situation. During an interview on 10/08/25 at 12:00 PM, Staff C, registered nurse (RN) House Supervisor, stated that during any code blue situation the team leader for the code blue would be the primary ER nurse that is working that day. Staff C, stated that on 06/11/25 the team leader for the 2 code blue patients that occurred would have been the primary ER nurse present at the time who would be the most experienced RN. Staff C, stated that a specific code blue team or team leader is not designated at the beginning of each shift by the house supervisor. ‘During an interview on 10/08/25 at 12:26 PM, Staff B, RN, Chief Nursing Officer (CNO), stated that in any code blue situation, any available clinical staff are to report to the code for assistance including EMS staff, ER staff, and house supervisors. Staff B, stated that the leader of the code blue should fall to the ER staff, EMS staff, or the physician. Staff B, stated that the house supervisor no longer makes a code blue team assignment and the procedure has changed since the beginning of the year but is not reflected on the current policy. During an interview on 10/08/25 at 1:20 PM, Staff D, RN, ER Director, stated that in the past the house supervisor would often act as the lead in code blue situations, but the process has changed in the last year to have an ER RN as the lead in code blue situations. Staff D, stated that the ER staff have more experience with code blue scenarios and would be expected to lead a code blue if one should occur. The CAH failed to update the code blue policy to reflect current practice of the hospital staff.”
The one inspection in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Oct 9, 2025 | Complaint inspection | 1 deficiency cited |
How do patients fare?
- CMS gives no overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.: “There are too few measures or measure groups reported to calculate a star rating or measure group score.”
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 0 better and 0 worse of 2; readmission, 0 better and 0 worse of 3.
- CMS gives no CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.: “The number of cases/patients is too few to report a star rating.”
- In CMS’s patient survey (Oct 1, 2024 to Sep 30, 2025): 88% rated it 9 or 10 out of 10, and 81% would definitely recommend it.
- Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): pneumonia 14.2%. CMS gives no comparison with the national rate for them in this release.
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): pneumonia 16.6%. CMS gives no comparison with the national rate for them in this release.
- After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate.
- Emergency department patients spent a median of 130 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 0% left before being seen.
- 45% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | Not rated |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | Not rated |
Is it certified, and in good standing?
- Medicare-certified critical access hospital since Jan 1, 2005.
- Ownership: government - local.
- It is not accredited by a private organisation, so the state carries out its routine inspections for Medicare.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency on record in the last three years.
- Government - Local.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- CMS’s HAC Reduction Program file has no result for it: the program covers general acute care hospitals Medicare pays under its inpatient prospective payment system.
- 1 deficiency cited in the last three years came from an inspection that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- 96% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- City of Fredonia runs it.
- 10 owners or officers are people: Joseph Morris (corporate director, 0%); Susan John (corporate director, 0%); Charlotte S Svaty (corporate director, 0%); Jennifer Friend (corporate director, 0%); Gaston Millar (corporate director, 0%); Jennifer E Jensik (corporate director, 0%); Johnathan Durrett (corporate officer, 0%); Johnathan Durrett (runs it (operational or managerial control), 0%); Evan Wayne Dunn (corporate director, 0%); Jennifer Lawrence (managing employee (on the payroll), 0%).
- CMS’s Provider of Services file records no change of ownership.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| City of Fredonia | Runs it (operational or managerial control) | 0% | Feb 8, 2007 |
How does it compare nearby?
- Of the 2 hospitals CMS lists in Wilson County, none has an overall star rating from CMS.
- CMS gives this hospital no overall star rating to compare.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
| Place | Overall star rating |
|---|---|
| Wilson Medical Center | Not given |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.