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
Staffing
Hours and turnover
RN hours / resident day
0.92
Registered nurse staffing
LPN hours / resident day
0.75
Licensed practical nurse staffing
Aide hours / resident day
2.51
Nurse aide staffing
Weekend hours
3.91
Weekend nurse staffing
RN turnover
20%
Annual RN turnover
Total nurse turnover
39%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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#3
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