Peabody, KS

Peabody Health And Rehab

5-star overall rating with 4-star inspections with $22,711 in total fines with 5 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle

407 N Locust Street, Peabody, KS

(620) 983-2152

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

45

Certified beds

Average residents

41

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Mission Health Communities

Operator or chain grouping

Approved since

2002-07-13

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

0.71

Registered nurse staffing · state 0.72 · national 0.68

LPN hours / resident day

0.14

Licensed practical nurse staffing · state 0.67 · national 0.87

Aide hours / resident day

2.17

Nurse aide staffing · state 2.69 · national 2.35

Total nurse hours

3.01

All reported nurse hours · state 4.07 · national 3.89

Licensed hours

0.84

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.78

Weekend nurse staffing · state 3.58 · national 3.43

Weekend RN hours

0.59

Weekend registered nurse coverage · state 0.50 · national 0.47

Physical therapist

0.00

Reported PT staffing · state 0.04 · national 0.07

Adjusted RN hours

1.01

CMS adjusted RN staffing hours

Adjusted total hours

4.31

CMS adjusted total nurse staffing hours

Case-mix index

0.96

Higher values indicate more complex resident acuity

RN turnover

33%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

55%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,781

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

15.33

Composite VBP score used to determine payment impact.

Payment multiplier

0.9815

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

0

Baseline 60.61% · Performance 67.57% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

3.07

Baseline 3.48 hours · Performance 3.95 hours · Measure score 3.07 · Achievement 3.07 · Improvement 1.55

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission Not Available
10.72%
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Discharge to community Not Available
50.57%
Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary 0.92
1.02
0.1 pts better
Drug regimen review with follow-up Not Available
95.27%
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Falls with major injury Not Available
0.77%
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Discharge self-care score Not Available
53.69%
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Discharge mobility score Not Available
50.94%
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened Not Available
2.29%
Numerator Not Available · Denominator 9 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization Not Available
7.12%
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage 5.56%
8.2%
2.6 pts worse
Numerator 3 · Denominator 54
Staff flu vaccination coverage 42.86%
42%
0.9 pts better
Numerator 30 · Denominator 70
Discharge function score Not Available
56.45%
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Transfer of health information to provider Not Available
95.95%
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Transfer of health information to patient Not Available
96.28%
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report.
Resident COVID-19 vaccinations up to date Not Available
25.2%
Numerator Not Available · Denominator 5 · 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 1.4
1.8
0.4 pts better
1.9
0.5 pts better
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 1.5
2.2
0.7 pts better
1.8
0.3 pts better
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.7 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 95.5%
91.8%
3.7 pts better
93.4%
2.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.1% · Q3 92.1% · Q4 95.0% · 4Q avg 95.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 95.1%
95.5%
0.4 pts worse
95.5%
0.4 pts worse
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.1%
Percentage of long-stay residents experiencing one or more falls with major injury 2.5%
4.4%
1.9 pts better
3.3%
0.8 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 5.3% · Q4 2.5% · 4Q avg 2.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 2.8%
5.6%
2.8 pts better
11.4%
8.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.1% · Q3 2.8% · Q4 0.0% · 4Q avg 2.8%
Percentage of long-stay residents who lose too much weight 10.3%
5.0%
5.3 pts worse
5.4%
4.9 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 13.9% · Q3 13.9% · Q4 8.1% · 4Q avg 10.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 14.2%
23.2%
9 pts better
19.6%
5.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 15.8% · Q3 8.1% · Q4 13.5% · 4Q avg 14.2%
Percentage of long-stay residents who received an antipsychotic medication 54.8%
19.8%
35 pts worse
16.7%
38.1 pts worse
Long Stay · 2024Q4-2025Q3 · 4Q avg 54.8% · 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 10.9%
18.4%
7.5 pts better
16.3%
5.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 18.7% · Q3 8.7% · Q4 11.2% · 4Q avg 10.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 9.6%
18.8%
9.2 pts better
14.9%
5.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 10.5% · Q3 13.5% · Q4 8.1% · 4Q avg 9.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.0%
1.8%
1.8 pts better
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% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 0.0%
3.1%
3.1 pts better
1.7%
1.7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 7.0%
23.2%
16.2 pts better
19.8%
12.8 pts better
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 4.9% · Q3 7.2% · Q4 11.0% · 4Q avg 7.0%
Percentage of long-stay residents with pressure ulcers 0.0%
4.6%
4.6 pts better
5.1%
5.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 95.8%
75.6%
20.2 pts better
81.7%
14.1 pts better
Short Stay · 2024Q4-2025Q3 · 4Q avg 95.8%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-30 · Fire 2025-01-30

5 health deficiencies

Top issue: Resident Rights (3 deficiencies)

13 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 2 Health 2023-02-27 · Fire 2023-02-27

12 health deficiencies

Top issue: Quality of Life and Care (8 deficiencies)

8 fire-safety deficiencies

Top issue: Smoke (6 deficiencies)

Cycle 3 Health 2021-09-03 · Fire 2021-09-03

6 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

12 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-01-30

K200 · Egress Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2025-04-25

F · Potential for more than minimal harm 2025-01-30

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2025-04-25

F · Potential for more than minimal harm 2025-01-30

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-03-03

F · Potential for more than minimal harm 2025-01-30

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-04-25

F · Potential for more than minimal harm 2025-01-30

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2025-04-25

F · Potential for more than minimal harm 2025-01-30

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-04-25

F · Potential for more than minimal harm 2025-01-30

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 2025-04-25

E · Potential for more than minimal harm 2025-01-30

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 2025-04-25

E · Potential for more than minimal harm 2025-01-30

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2025-04-25

E · Potential for more than minimal harm 2025-01-30

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-04-25

E · Potential for more than minimal harm 2025-01-30

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-04-25

E · Potential for more than minimal harm 2025-01-30

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-04-25

E · Potential for more than minimal harm 2025-01-30

K761 · Miscellaneous Deficiencies

Fire Safety

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

Corrected 2025-04-25

F · Potential for more than minimal harm 2023-02-27

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 2023-03-31

F · Potential for more than minimal harm 2023-02-27

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 2023-03-31

F · Potential for more than minimal harm 2023-02-27

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-03-31

F · Potential for more than minimal harm 2023-02-27

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2023-03-31

F · Potential for more than minimal harm 2023-02-27

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-03-31

F · Potential for more than minimal harm 2023-02-27

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-03-31

F · Potential for more than minimal harm 2023-02-27

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-03-31

F · Potential for more than minimal harm 2023-02-27

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-03-31

F · Potential for more than minimal harm 2021-09-03

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2021-11-05

F · Potential for more than minimal harm 2021-09-03

E7 · Emergency Preparedness Deficiencies

Fire Safety

Address patient/client population and determine types of services needed.

Corrected 2021-11-05

F · Potential for more than minimal harm 2021-09-03

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 2021-11-05

F · Potential for more than minimal harm 2021-09-03

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2021-11-05

F · Potential for more than minimal harm 2021-09-03

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2021-11-05

F · Potential for more than minimal harm 2021-09-03

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2021-11-05

F · Potential for more than minimal harm 2021-09-03

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2021-11-05

F · Potential for more than minimal harm 2021-09-03

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2021-11-05

F · Potential for more than minimal harm 2021-09-03

K912 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have power receptacles that are properly grounded.

Corrected 2021-11-05

E · Potential for more than minimal harm 2021-09-03

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2021-11-05

D · Potential for more than minimal harm 2021-09-03

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2021-11-05

D · Potential for more than minimal harm 2021-09-03

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2021-11-05

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-01-30

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 2025-02-27

D · Potential for more than minimal harm 2025-01-30

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2025-02-27

D · Potential for more than minimal harm 2025-01-30

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2025-02-27

D · Potential for more than minimal harm 2025-01-30

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2025-02-27

D · Potential for more than minimal harm 2025-01-30

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected 2025-02-27

J · Immediate jeopardy 2024-03-18

F742 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Corrected 2024-03-12

J · Immediate jeopardy 2023-11-07

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 2023-11-02

G · Actual harm 2023-02-27

F692 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-03-29

F · Potential for more than minimal harm 2023-02-27

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2023-03-29

D · Potential for more than minimal harm 2023-02-27

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 2023-03-29

D · Potential for more than minimal harm 2023-02-27

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2023-03-29

D · Potential for more than minimal harm 2023-02-27

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2023-03-29

D · Potential for more than minimal harm 2023-02-27

F676 · Quality of Life and Care Deficiencies

Health

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected 2023-03-29

D · Potential for more than minimal harm 2023-02-27

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 2023-03-29

D · Potential for more than minimal harm 2023-02-27

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-03-29

D · Potential for more than minimal harm 2023-02-27

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-03-29

D · Potential for more than minimal harm 2023-02-27

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 2023-03-29

D · Potential for more than minimal harm 2023-02-27

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-03-29

E · Potential for more than minimal harm 2021-09-03

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 2021-10-03

D · Potential for more than minimal harm 2021-09-03

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 2021-10-03

D · Potential for more than minimal harm 2021-09-03

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2021-10-03

D · Potential for more than minimal harm 2021-09-03

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2021-10-03

D · Potential for more than minimal harm 2021-09-03

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 2021-10-03

Penalties and ownership

What sits behind the stars

$14,518 2024-03-18

Fine

Fine · fine $14,518

Fine

$8,193 2023-11-07

Fine

Fine · fine $8,193

Fine

Ownership

Kansas Operator LLC

5% Or Greater Direct Ownership Interest · Organization

100% 11 facilities 2015-02-25
Barres, LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 40 facilities 2015-02-26
Borzumato, Andrew

Operational/Managerial Control · Individual

0% 2 facilities 2015-02-26
Crino, Bryan

5% Or Greater Indirect Ownership Interest · Individual

0% 25 facilities 2015-02-26
Feuer, Scott

5% Or Greater Indirect Ownership Interest · Individual

0% 25 facilities 2015-02-26
Lindeman, Stuart

5% Or Greater Indirect Ownership Interest · Individual

0% 40 facilities 2015-02-26
Lindeman, Stuart

Corporate Officer · Individual

0% 40 facilities 2015-02-26
Mission Health Communities, LLC

Operational/Managerial Control · Organization

0% 28 facilities 2015-02-26
Parmley, Melissa

Operational/Managerial Control · Individual

0% 1 facilities 2015-02-26
Passero, Joseph

5% Or Greater Indirect Ownership Interest · Individual

0% 24 facilities 2015-02-26
Russell, Richard

Operational/Managerial Control · Individual

0% 1 facilities 2015-02-26
Russell, Richard

Corporate Officer · Individual

0% 1 facilities 2015-02-26
T And C Capital Assets, LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 39 facilities 2015-02-26
Windward Health Partners LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 40 facilities 2015-02-26

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