5 health deficiencies
Top issue: Resident Rights (3 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Peabody, KS
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
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
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
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
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
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
| 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
| 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
Top issue: Resident Rights (3 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Quality of Life and Care (8 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire Safety
Meet other general requirements.
Corrected 2025-04-25
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-04-25
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-03
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-25
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-04-25
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-25
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
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
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
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-04-25
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-25
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-25
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-04-25
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
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
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-31
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-31
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-31
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-31
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-31
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-31
Fire Safety
Implement emergency and standby power systems.
Corrected 2021-11-05
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2021-11-05
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
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-11-05
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-11-05
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-11-05
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-11-05
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-11-05
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2021-11-05
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-11-05
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-11-05
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-11-05
Inspection history
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
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-02-27
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
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
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
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
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-02
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-03-29
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-03-29
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-03-29
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
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
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-03-29
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-03-29
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-29
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-29
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-03-29
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-03-29
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
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-10-03
Health
Provide activities to meet all resident's needs.
Corrected 2021-10-03
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-10-03
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
Fine · fine $14,518
Fine
Fine · fine $8,193
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Peabody, KS
0-star overall rating with 0-star inspections with Special Focus status with $100,231 in total fines with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
Hillsboro, KS
1-star overall rating with 1-star inspections with $72,818 in total fines with 19 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
Hillsboro, KS
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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