Cycle 1
Health 2024-06-12 · Fire 2024-06-12
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Neodesha, KS
Neodesha Care And Rehab
4-star overall rating with 4-star inspections with $11,911 in total fines with 4 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
1626 N 8th Street, Neodesha, KS
(620) 325-3088
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
45
Certified beds
Average residents
44
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Mission Health Communities
Operator or chain grouping
Approved since
1994-08-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.43
Registered nurse staffing
LPN hours / resident day
0.63
Licensed practical nurse staffing
Aide hours / resident day
2.43
Nurse aide staffing
Weekend hours
3.18
Weekend nurse staffing
RN turnover
50%
Annual RN turnover
Total nurse turnover
34%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.8
0.3 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.2 |
2.2
2 pts worse
|
1.8
2.4 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.3% |
91.8%
6.5 pts worse
|
93.4%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.7% |
95.5%
1.2 pts better
|
95.5%
1.2 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
4.4%
3 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 24.4% |
5.6%
18.8 pts worse
|
11.4%
13 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.4% |
5.0%
0.6 pts better
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.3% |
23.2%
4.1 pts worse
|
19.6%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 17.1% |
19.8%
2.7 pts better
|
16.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.0% |
18.4%
1.4 pts better
|
16.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.3% |
18.8%
0.5 pts worse
|
14.9%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.6% |
1.8%
1.8 pts worse
|
1.0%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.2% |
23.2%
About the same
|
19.8%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
4.6%
0.4 pts worse
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 44.8% |
73.5%
28.7 pts worse
|
79.7%
34.9 pts worse
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-30 · Fire 2022-11-30
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
12 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2021-06-30 · Fire 2021-06-30
7 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
L · Immediate jeopardy
2024-06-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-31
F · Potential for more than minimal harm
2024-06-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-15
F · Potential for more than minimal harm
2024-06-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-31
F · Potential for more than minimal harm
2024-06-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-07-31
F · Potential for more than minimal harm
2024-06-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-31
E · Potential for more than minimal harm
2024-06-12
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 2024-07-31
E · Potential for more than minimal harm
2024-06-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-07-31
E · Potential for more than minimal harm
2024-06-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-06-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-06-12
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-07-31
F · Potential for more than minimal harm
2022-11-30
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-01-25
F · Potential for more than minimal harm
2022-11-30
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 2023-01-25
F · Potential for more than minimal harm
2022-11-30
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-01-25
F · Potential for more than minimal harm
2022-11-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-25
F · Potential for more than minimal harm
2022-11-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-25
F · Potential for more than minimal harm
2022-11-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-01-25
F · Potential for more than minimal harm
2022-11-30
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-01-25
F · Potential for more than minimal harm
2022-11-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-25
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 2023-01-25
F · Potential for more than minimal harm
2022-11-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-25
F · Potential for more than minimal harm
2022-11-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-01-25
E · Potential for more than minimal harm
2022-11-30
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-01-25
F · Potential for more than minimal harm
2021-06-30
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2021-09-17
F · Potential for more than minimal harm
2021-06-30
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2021-09-17
F · Potential for more than minimal harm
2021-06-30
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2021-09-17
F · Potential for more than minimal harm
2021-06-30
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 2021-09-17
F · Potential for more than minimal harm
2021-06-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-09-17
F · Potential for more than minimal harm
2021-06-30
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2021-09-17
F · Potential for more than minimal harm
2021-06-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-09-17
F · Potential for more than minimal harm
2021-06-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-09-17
F · Potential for more than minimal harm
2021-06-30
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-09-17
F · Potential for more than minimal harm
2021-06-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-09-17
F · Potential for more than minimal harm
2021-06-30
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 2021-09-17
F · Potential for more than minimal harm
2021-06-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-09-17
F · Potential for more than minimal harm
2021-06-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-09-17
E · Potential for more than minimal harm
2021-06-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-06-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-09-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-02-12
F · Potential for more than minimal harm
2024-06-12
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 2024-06-20
F · Potential for more than minimal harm
2024-06-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-06-12
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 2024-06-20
G · Actual harm
2022-11-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-12-13
D · Potential for more than minimal harm
2022-11-30
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 2022-12-13
D · Potential for more than minimal harm
2022-11-30
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-12-13
F · Potential for more than minimal harm
2021-06-30
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 2021-07-30
F · Potential for more than minimal harm
2021-06-30
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 2021-07-30
E · Potential for more than minimal harm
2021-06-30
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2021-07-30
D · Potential for more than minimal harm
2021-06-30
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 2021-07-30
D · Potential for more than minimal harm
2021-06-30
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 2021-07-30
D · Potential for more than minimal harm
2021-06-30
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-07-30
D · Potential for more than minimal harm
2021-06-30
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 2021-07-30
Penalties and ownership
What sits behind the stars
$11,911
2024-07-15
Fine
Fine · fine $11,911
Fine
$0
2024-07-15
Payment Denial
Payment Denial · denial start 2024-07-31 · 51 days
51 day denial
Ownership
Coronado Operator, LLC
5% Or Greater Direct Ownership Interest · Organization
Barres, LLC
5% Or Greater Indirect Ownership Interest · Organization
Curis Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Lindeman, Stuart
Operational/Managerial Control · Individual
Mission Health Communities, LLC
Operational/Managerial Control · Organization
Neodesha Operator, LLC
Operational/Managerial Control · Organization
T And C Capital Assets, LLC
5% Or Greater Indirect Ownership Interest · Organization
Thomas, Tina
Operational/Managerial Control · Individual
Windward Health Partners LLC
5% Or Greater Indirect Ownership Interest · Organization
Yoakum, Jamie
Operational/Managerial Control · Individual
Yoakum, Jamie
Corporate Officer · Individual
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#3
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