Cycle 1
Health 2024-08-29 · Fire 2024-08-29
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Lansing, KS
Twin Oaks Health And Rehab
5-star overall rating with 4-star inspections with $14,521 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
757 W Eisenhower Rd, Lansing, KS
(913) 534-8336
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
57
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Midwest Health
Operator or chain grouping
Approved since
2013-02-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 3 overall / 3 health / 4 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
0.92
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.51
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.18
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.67
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.91
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.77
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.21
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.97
CMS adjusted RN staffing hours
Adjusted total hours
4.43
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,762
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.13
Composite VBP score used to determine payment impact.
Payment multiplier
1.0090
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.77
Baseline 21.71% · Performance 20.18% · Measure score 2.77 · Achievement 2.70 · Improvement 2.77
Healthcare-associated infections
8.64
Baseline 6.06% · Performance 5.25% · Measure score 8.64 · Achievement 8.64 · Improvement 7.08
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
4.83
Baseline 3.87 hours · Performance 4.45 hours · Measure score 4.83 · Achievement 4.83 · Improvement 2.54
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13% |
10.72%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 296 · Observed rate 14.53% · Lower 95% interval 10.28% |
| Discharge to community | 61.05% |
50.57%
10.5 pts better
|
Better than the National Rate · Eligible stays 287 · Observed rate 57.14% · Lower 95% interval 55.68% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.11% |
95.27%
3.8 pts better
|
Numerator 223 · Denominator 225 |
| Falls with major injury | 0.44% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 225 |
| Discharge self-care score | 48.15% |
53.69%
5.5 pts worse
|
Numerator 78 · Denominator 162 |
| Discharge mobility score | 30.86% |
50.94%
20.1 pts worse
|
Numerator 50 · Denominator 162 |
| Pressure ulcers or injuries, new or worsened | 3.56% |
2.29%
1.3 pts worse
|
Numerator 8 · Denominator 225 · Adjusted rate 4.42% |
| Healthcare-associated infections requiring hospitalization | 5.25% |
7.12%
1.9 pts better
|
No Different than the National Rate · Eligible stays 208 · Observed rate 3.37% · Lower 95% interval 3.72% |
| Staff COVID-19 vaccination coverage | 2.08% |
8.2%
6.1 pts worse
|
Numerator 2 · Denominator 96 |
| Staff flu vaccination coverage | 73.74% |
42%
31.7 pts better
|
Numerator 73 · Denominator 99 |
| Discharge function score | 33.95% |
56.45%
22.5 pts worse
|
Numerator 55 · Denominator 162 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 167 · Denominator 167 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 26 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | 21.7% |
25.2%
3.5 pts worse
|
Numerator 23 · Denominator 106 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.8
0.2 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.5 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
2.2
1.3 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.0% |
91.8%
4.2 pts better
|
93.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 94.6% · Q3 100.0% · Q4 89.5% · 4Q avg 96.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.5% |
95.5%
2 pts better
|
95.5%
2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
4.4%
0.4 pts better
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 5.4% · Q3 2.8% · Q4 2.6% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
5.6%
4.2 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 2.6% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 8.0% |
5.0%
3 pts worse
|
5.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 15.4% · Q3 7.1% · Q4 0.0% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.0% |
23.2%
4.2 pts better
|
19.6%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 14.3% · Q3 24.1% · Q4 25.0% · 4Q avg 19.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.0% |
19.8%
5.8 pts better
|
16.7%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 18.2% · Q3 13.0% · Q4 9.1% · 4Q avg 14.0% · 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 | 11.6% |
18.4%
6.8 pts better
|
16.3%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.5% |
18.8%
3.3 pts better
|
14.9%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 14.3% · Q3 13.8% · Q4 10.7% · 4Q avg 15.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
1.8%
0.5 pts better
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
3.1%
2.4 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.6% |
23.2%
2.4 pts worse
|
19.8%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.9% · Q2 19.4% · Q3 31.6% · Q4 17.7% · 4Q avg 25.6% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
4.6%
1.4 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 4.9% · Q3 6.5% · Q4 9.0% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.9% |
75.6%
10.3 pts better
|
81.7%
4.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 83.6% · Q2 88.4% · Q3 86.8% · Q4 85.0% · 4Q avg 85.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.2% |
11.7%
0.5 pts better
|
12.0%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.2% · Observed 10.4% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
2.2%
1.4 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.1% · Q4 0.9% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.3% |
73.5%
14.8 pts better
|
79.7%
8.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 36.1% |
23.0%
13.1 pts worse
|
23.9%
12.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 36.1% · Observed 30.5% · Expected 20.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-23 · Fire 2023-02-23
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2021-08-23 · Fire 2021-08-23
7 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-08-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-04
F · Potential for more than minimal harm
2023-02-23
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2023-05-04
F · Potential for more than minimal harm
2023-02-23
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2023-05-04
F · Potential for more than minimal harm
2023-02-23
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-05-04
F · Potential for more than minimal harm
2023-02-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-04
F · Potential for more than minimal harm
2021-08-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-09-20
F · Potential for more than minimal harm
2021-08-23
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2021-09-20
E · Potential for more than minimal harm
2021-08-23
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-09-20
E · Potential for more than minimal harm
2021-08-23
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 2021-09-20
E · Potential for more than minimal harm
2021-08-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-09-20
E · Potential for more than minimal harm
2021-08-23
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-09-20
D · Potential for more than minimal harm
2021-08-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-09-20
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-08-29
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 2024-11-21
E · Potential for more than minimal harm
2024-08-29
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-08-29
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 2024-11-21
D · Potential for more than minimal harm
2024-08-29
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 2024-11-21
D · Potential for more than minimal harm
2024-08-29
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-08-29
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-11-21
C · Minimal harm
2024-08-29
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-11-21
J · Immediate jeopardy
2023-07-24
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 2023-07-17
D · Potential for more than minimal harm
2023-02-23
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 2023-04-08
D · Potential for more than minimal harm
2023-02-23
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 2023-04-08
D · Potential for more than minimal harm
2023-02-23
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-04-08
D · Potential for more than minimal harm
2023-02-23
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-04-08
E · Potential for more than minimal harm
2021-08-23
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 2021-09-23
E · Potential for more than minimal harm
2021-08-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-09-23
D · Potential for more than minimal harm
2021-08-23
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 2021-09-23
D · Potential for more than minimal harm
2021-08-23
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 2021-09-23
D · Potential for more than minimal harm
2021-08-23
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-09-23
D · Potential for more than minimal harm
2021-08-23
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 2021-09-23
Penalties and ownership
What sits behind the stars
$14,521
2023-07-24
Fine
Fine · fine $14,521
Fine
Ownership
Twin Oaks Health And Rehab Operations LLC
5% Or Greater Direct Ownership Interest · Organization
Collins, Dana
Operational/Managerial Control · Individual
Eaton, Floyd
Operational/Managerial Control · Individual
Floyd C Eaton Iii Trust 2012
5% Or Greater Indirect Ownership Interest · Organization
James Brett Klausman Trust 2012
5% Or Greater Indirect Ownership Interest · Organization
Jamie N Eaton Trust 2012
5% Or Greater Indirect Ownership Interest · Organization
Klaton Holding Co #2, Inc
5% Or Greater Indirect Ownership Interest · Organization
Klausman, James
Operational/Managerial Control · Individual
Michael Graham Klausman Trust 2012
5% Or Greater Indirect Ownership Interest · Organization
Midwest Health, Inc. 06122001
Operational/Managerial Control · Organization
Twin Oaks Health And Rehab Operations LLC
Operational/Managerial Control · Organization
Twin Oaks Independent Living, Inc.
5% Or Greater Indirect Ownership Interest · Organization
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