Minneola, KS

Minneola District Hospital Ltcu

2-star overall rating with 1-star inspections with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

207 Chestnut, Minneola, KS

(620) 885-4238

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1977-01-26

CMS approved date

Coverage

Medicaid

Participation flags

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Hospital-based

Yes

CMS reports the provider resides in a hospital

Staffing

Hours and turnover

RN hours / resident day

1.94

Registered nurse staffing · state 0.72 · national 0.68

LPN hours / resident day

0.35

Licensed practical nurse staffing · state 0.67 · national 0.87

Aide hours / resident day

4.13

Nurse aide staffing · state 2.69 · national 2.35

Total nurse hours

6.42

All reported nurse hours · state 4.07 · national 3.89

Licensed hours

2.29

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

5.57

Weekend nurse staffing · state 3.58 · national 3.43

Weekend RN hours

1.42

Weekend registered nurse coverage · state 0.50 · national 0.47

Physical therapist

0.00

Reported PT staffing

Adjusted RN hours

2.36

CMS adjusted RN staffing hours

Adjusted total hours

7.80

CMS adjusted total nurse staffing hours

Case-mix index

1.13

Higher values indicate more complex resident acuity

RN turnover

25%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

35%

Annual nurse turnover · state 50% · national 46%

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Medicare spending per beneficiary	Not Available	1.02	This provider is not required to submit SNF QRP data.
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · This provider is not required to submit SNF QRP data.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Staff COVID-19 vaccination coverage	Not Available	8.2%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	95.7%	91.8% 3.9 pts better	93.4% 2.3 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 95.7%
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	2.9%	4.4% 1.5 pts better	3.3% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 2.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.6%	5.6% 4 pts better	11.4% 9.8 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 1.6%
Percentage of long-stay residents who lose too much weight	1.5%	5.0% 3.5 pts better	5.4% 3.9 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 1.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	8.8%	23.2% 14.4 pts better	19.6% 10.8 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 8.8%
Percentage of long-stay residents who received an antipsychotic medication	18.0%	19.8% 1.8 pts better	16.7% 1.3 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 18.0% · 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 · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	14.3%	18.4% 4.1 pts better	16.3% 2 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 14.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	11.8%	18.8% 7 pts better	14.9% 3.1 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 11.8% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	3.1%	1.8% 1.3 pts worse	1.0% 2.1 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 3.1% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	7.1%	3.1% 4 pts worse	1.7% 5.4 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 7.1% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	27.8%	23.2% 4.6 pts worse	19.8% 8 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 27.8%
Percentage of long-stay residents with pressure ulcers	1.4%	4.6% 3.2 pts better	5.1% 3.7 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 1.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-03-04 · Fire 2025-03-04

12 health deficiencies

Top issue: Pharmacy Service (4 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2023-03-02 · Fire 2023-03-02

9 health deficiencies

Top issue: Resident Assessment and Care Planning (5 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2021-07-15 · Fire 2021-07-15

2 health deficiencies

Top issue: Infection Control (1 deficiency)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-03-04

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2025-04-01

F · Potential for more than minimal harm 2025-03-04

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-04-01

D · Potential for more than minimal harm 2025-03-04

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 2025-04-01

F · Potential for more than minimal harm 2023-03-02

K131 · Construction Deficiencies

Fire Safety

Meet requirements for sections of health care facilities separated by fire resistive construction.

Corrected 2023-03-30

F · Potential for more than minimal harm 2023-03-02

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-03-30

F · Potential for more than minimal harm 2023-03-02

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-03-30

F · Potential for more than minimal harm 2023-03-02

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-03-30

F · Potential for more than minimal harm 2021-07-15

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2021-07-27

E · Potential for more than minimal harm 2021-07-15

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2021-07-27

Inspection history

Recent health citations

J · Immediate jeopardy 2025-03-04

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 2025-03-28

G · Actual harm 2025-03-04

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2025-03-28

F · Potential for more than minimal harm 2025-03-04

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 2025-03-28

F · Potential for more than minimal harm 2025-03-04

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 2025-03-28

F · Potential for more than minimal harm 2025-03-04

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-28

F · Potential for more than minimal harm 2025-03-04

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2025-03-28

E · Potential for more than minimal harm 2025-03-04

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 2025-03-28

E · Potential for more than minimal harm 2025-03-04

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2025-03-28

E · Potential for more than minimal harm 2025-03-04

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-03-28

E · Potential for more than minimal harm 2025-03-04

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 2025-03-28

E · Potential for more than minimal harm 2025-03-04

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 2025-03-28

C · Minimal harm 2025-03-04

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2025-03-28

F · Potential for more than minimal harm 2023-03-02