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
Chain footprint
40 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
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
0.43
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.43
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.49
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.06
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.18
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
3.39
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,746
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.75
Composite VBP score used to determine payment impact.
Payment multiplier
0.9918
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
6.49
Baseline 48.65% · Performance 37.14% · Measure score 6.49 · Achievement 6.49 · Improvement 4.33
Adjusted total nurse staffing
1.26
Baseline 3.17 hours · Performance 3.44 hours · Measure score 1.26 · Achievement 1.26 · Improvement 0.51
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.1% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 44 · Observed rate 13.64% · Lower 95% interval 7.35% |
| Discharge to community | 40.46% |
50.57%
10.1 pts worse
|
No Different than the National Rate · Eligible stays 26 · Observed rate 30.77% · Lower 95% interval 26.92% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 96.15% |
95.27%
0.9 pts better
|
Numerator 25 · Denominator 26 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 26 |
| Discharge self-care score | 47.83% |
53.69%
5.9 pts worse
|
Numerator 11 · Denominator 23 |
| Discharge mobility score | 26.09% |
50.94%
24.8 pts worse
|
Numerator 6 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 7.69% |
2.29%
5.4 pts worse
|
Numerator 2 · Denominator 26 · Adjusted rate 7.37% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.92% |
8.2%
6.3 pts worse
|
Numerator 1 · Denominator 52 |
| Staff flu vaccination coverage | 96.23% |
42%
54.2 pts better
|
Numerator 51 · Denominator 53 |
| Discharge function score | 52.17% |
56.45%
4.3 pts worse
|
Numerator 12 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · 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 | 2.1 |
1.8
0.3 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.4 · Expected 2.2 · Used in QM five-star |
| 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 · Adjusted 4.2 · Observed 4.8 · Expected 1.9 · Used in QM five-star |
| 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 · Q1 90.0% · Q2 86.7% · Q3 82.9% · Q4 83.3% · 4Q avg 85.3% |
| 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 · 4Q avg 96.7% |
| 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 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 2.4% · 4Q avg 1.4% · Used in QM five-star |
| 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 · Q1 35.7% · Q2 23.1% · Q3 20.5% · Q4 21.4% · 4Q avg 24.4% |
| 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 · Q1 6.7% · Q2 3.4% · Q3 0.0% · Q4 7.7% · 4Q avg 4.4% |
| 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 · Q1 26.7% · Q2 23.3% · Q3 28.2% · Q4 30.0% · 4Q avg 27.3% |
| 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 · Q2 20.0% · Q3 15.2% · Q4 14.7% · 4Q avg 17.1% · 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 | 17.0% |
18.4%
1.4 pts better
|
16.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.0% · Used in QM five-star |
| 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 · Q1 13.3% · Q2 16.7% · Q3 16.7% · Q4 28.2% · 4Q avg 19.3% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 2.8% · Q3 6.2% · Q4 4.1% · 4Q avg 3.6% · 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 · Q1 6.7% · Q2 10.3% · Q3 4.9% · Q4 7.3% · 4Q avg 7.1% · Used in QM five-star |
| 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 · Q1 24.1% · Q2 20.0% · Q3 22.6% · Q4 25.6% · 4Q avg 23.2% |
| 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 · Q1 7.0% · Q2 2.3% · Q3 6.9% · Q4 3.4% · 4Q avg 5.0% · Used in QM five-star |
| 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 · Q1 40.0% · Q2 62.1% · 4Q avg 50.0% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
| 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 · 4Q avg 44.8% |
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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#2
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2-star overall rating with 3-star inspections with 13 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Montgomery Place Nursing Center
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4-star overall rating with 4-star inspections with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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