Cycle 1
Health 2025-12-30 · Fire 2025-12-30
5 health deficiencies
Top issue: Administration (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Oswego, KS
Oswego Operator, LLC
3-star overall rating with 4-star inspections with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
1104 Ohio Street, Oswego, KS
(620) 795-4429
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
40
Certified beds
Average residents
34
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Mission Health Communities
Operator or chain grouping
Approved since
1999-01-27
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
1.02
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.22
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.72
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.95
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.23
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.19
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.75
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
0.96
CMS adjusted RN staffing hours
Adjusted total hours
3.75
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
39%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,730
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.08
Composite VBP score used to determine payment impact.
Payment multiplier
1.0018
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
7.99
Baseline 33.33% · Performance 31.03% · Measure score 7.99 · Achievement 7.99 · Improvement 2.21
Adjusted total nurse staffing
1.63
Baseline 3.51 hours · Performance 3.54 hours · Measure score 1.63 · Achievement 1.63 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.64% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 14.29% · Lower 95% interval 7.63% |
| Discharge to community | 56.44% |
50.57%
5.9 pts better
|
No Different than the National Rate · Eligible stays 29 · Observed rate 58.62% · Lower 95% interval 40.77% |
| Medicare spending per beneficiary | 1.23 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 32 · Denominator 32 |
| Falls with major injury | 3.13% |
0.77%
2.4 pts worse
|
Numerator 1 · Denominator 32 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 9.38% |
2.29%
7.1 pts worse
|
Numerator 3 · Denominator 32 · Adjusted rate 7.32% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 55 |
| Staff flu vaccination coverage | 43.33% |
42%
1.3 pts better
|
Numerator 26 · Denominator 60 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · 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 | 2.0 |
1.8
0.2 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.9 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.0 |
2.2
0.8 pts worse
|
1.8
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.9 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.6% |
91.8%
2.2 pts worse
|
93.4%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 88.0% · Q2 84.0% · Q3 90.3% · Q4 94.1% · 4Q avg 89.6% |
| 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 | 4.3% |
4.4%
0.1 pts better
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.0% · Q3 6.5% · Q4 2.9% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
5.6%
4.7 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
5.0%
1 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 0.0% · Q3 7.4% · Q4 3.3% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.5% |
23.2%
6.3 pts worse
|
19.6%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.8% · Q2 31.8% · Q3 27.6% · Q4 25.8% · 4Q avg 29.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.3% |
19.8%
2.5 pts better
|
16.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 14.3% · Q4 10.0% · 4Q avg 17.3% · 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 | 16.6% |
18.4%
1.8 pts better
|
16.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.8% |
18.8%
11 pts better
|
14.9%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 0.0% · Q3 14.8% · Q4 3.3% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
1.8%
0.7 pts better
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 11.8% |
3.1%
8.7 pts worse
|
1.7%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.7% · Q3 17.2% · Q4 18.2% · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.0% |
23.2%
3.2 pts better
|
19.8%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.3% · Q2 15.2% · Q3 24.1% · Q4 15.5% · 4Q avg 20.0% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
4.6%
1.6 pts worse
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 11.4% · Q3 2.4% · Q4 4.0% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 54.9% |
75.6%
20.7 pts worse
|
81.7%
26.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 50.0% · Q2 60.6% · Q3 65.0% · 4Q avg 54.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.5% |
11.7%
4.8 pts worse
|
12.0%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.5% · Observed 17.9% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 12.8% |
2.2%
10.6 pts worse
|
1.6%
11.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 12.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 57.1% |
73.5%
16.4 pts worse
|
79.7%
22.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 57.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.0% |
23.0%
11 pts worse
|
23.9%
10.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.0% · Observed 39.3% · Expected 27.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-20 · Fire 2024-05-20
5 health deficiencies
Top issue: Infection Control (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2022-08-16 · Fire 2022-08-16
8 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
9 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-30
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2026-02-17
F · Potential for more than minimal harm
2025-12-30
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 2026-02-03
F · Potential for more than minimal harm
2025-12-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2026-02-17
E · Potential for more than minimal harm
2025-12-30
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 2026-02-17
E · Potential for more than minimal harm
2025-12-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-02-17
E · Potential for more than minimal harm
2025-12-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2026-02-17
E · Potential for more than minimal harm
2025-12-30
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 2026-02-18
D · Potential for more than minimal harm
2025-12-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2026-02-17
D · Potential for more than minimal harm
2025-12-30
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2026-02-17
F · Potential for more than minimal harm
2024-05-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-15
F · Potential for more than minimal harm
2024-05-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-15
F · Potential for more than minimal harm
2024-05-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-15
E · Potential for more than minimal harm
2024-05-20
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 2024-07-15
E · Potential for more than minimal harm
2024-05-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-15
E · Potential for more than minimal harm
2024-05-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-05-20
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-05-20
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-05-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-05-20
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 2024-07-15
F · Potential for more than minimal harm
2022-08-16
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2022-11-10
F · Potential for more than minimal harm
2022-08-16
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-11-10
F · Potential for more than minimal harm
2022-08-16
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 2022-11-10
F · Potential for more than minimal harm
2022-08-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-10
F · Potential for more than minimal harm
2022-08-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-10
F · Potential for more than minimal harm
2022-08-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-11-10
E · Potential for more than minimal harm
2022-08-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-11-10
E · Potential for more than minimal harm
2022-08-16
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-11-10
D · Potential for more than minimal harm
2022-08-16
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-11-10
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-30
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 2026-01-31
F · Potential for more than minimal harm
2025-12-30
F924 · Environmental Deficiencies
Health
Put firmly secured handrails on each side of hallways.
Corrected 2026-01-31
D · Potential for more than minimal harm
2025-12-30
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-01-31
D · Potential for more than minimal harm
2025-12-30
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-01-31
C · Minimal harm
2025-12-30
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 2026-01-31
F · Potential for more than minimal harm
2024-05-20
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 2024-06-10
F · Potential for more than minimal harm
2024-05-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-10
D · Potential for more than minimal harm
2024-05-20
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 2024-06-10
D · Potential for more than minimal harm
2024-05-20
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 2024-06-10
D · Potential for more than minimal harm
2024-05-20
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-06-10
G · Actual harm
2022-08-16
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 2022-09-02
D · Potential for more than minimal harm
2022-08-16
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2022-09-02
D · Potential for more than minimal harm
2022-08-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-09-02
D · Potential for more than minimal harm
2022-08-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-09-02
D · Potential for more than minimal harm
2022-08-16
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 2022-09-02
D · Potential for more than minimal harm
2022-08-16
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 2022-09-02
D · Potential for more than minimal harm
2022-08-16
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-09-02
D · Potential for more than minimal harm
2022-08-16
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 2022-09-02
Penalties and ownership
What sits behind the stars
Ownership
Kansas Operator LLC
5% Or Greater Direct Ownership Interest · Organization
Barres, LLC
5% Or Greater Indirect Ownership Interest · Organization
Crino, Bryan
5% Or Greater Indirect Ownership Interest · Individual
Feuer, Scott
5% Or Greater Indirect Ownership Interest · Individual
Kansas Operator LLC
Operational/Managerial Control · Organization
Lindeman, Stuart
5% Or Greater Indirect Ownership Interest · Individual
Lindeman, Stuart
Corporate Officer · Individual
Mission Health Communities, LLC
Operational/Managerial Control · Organization
Passero, Joseph
5% Or Greater Indirect Ownership Interest · Individual
T And C Capital Assets, LLC
5% Or Greater Indirect Ownership Interest · Organization
Windward Health Partners LLC
5% Or Greater Indirect Ownership Interest · Organization
Yoakum, Jamie
Operational/Managerial Control · Individual
Yoakum, Jamie
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Medicalodges Columbus
Columbus, KS
3-star overall rating with 3-star inspections with $13,397 in total fines with 11 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Elmhaven East
Parsons, KS
2-star overall rating with 2-star inspections with $53,504 in total fines with 12 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Good Samaritan Society - Parsons
Parsons, KS
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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