Neodesha Care And Rehab
1626 N 8th Street, Neodesha, KS 66757 · For profit - Limited Liability company · 45 certified beds · (620) 325-3088 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (26% vs 45% nationally) — better care continuity
- it has 1 actual-harm citation
- a high number of inspection citations overall (18) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $11,911 in federal fines (most recent 2024-07-15)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 22.4% | 17.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.2% | 4.9% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 3.3% | 1.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 5.5% | 2.9% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 18.5% | 6.5% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.4% | 4.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 20.3% | 16.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 35.2% | 23.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 96.7% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.2% | 4.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 22.4% | 22.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.4% | 18.1% | 17.1% | better |
| Short-stay residents given the seasonal flu vaccine | 44.8% | 73.8% | 79.4% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.27 | 1.80 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.87 | 2.13 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
40.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 26 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 71.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 21 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.28 therapist hours per resident per day in 2026Q1 — more than 42% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 40.5%CMS range 26.9–55.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.1%CMS range 7.3–16.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 71.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 57.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 38.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 95.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 9.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.08 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 45 beds and averages 39.6 residents a day — about 88% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.93 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.550 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.58 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.42 hrs/resident/day on weekends vs 4.14 on weekdays — 17% thinner on weekends. RN hours go from 0.61 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 26% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
18 citations, most serious first. The 11 most serious are shown; the remaining 7 are one tap away and print in full.
- Actual harm · G2022-11-30 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 36 residents, with 12 sampled, including four residents sampled for pressure ulcers. Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards to prevent pressure ulcers (PU, localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) by failure to perform skin assessments under a medical immobilization device for Resident (R) 3, allowing an unstageable (full thickness tissue loss in which actual. depth of the ulcer is completely obscured) PU to develop. Findings included: - The 11/28/22 Electronic Health Record (EHR) documented R3 had the following diagnoses: fracture of the left tibia (bone of the lower leg) and fibula (one of the two bones of the lower leg) shafts on the left side, hemiparesis (muscular weakness of one half of the body) on the left, hemiplegia (paralysis of one side of the body) on the left, and peripheral vascular disease (PVD- abnormal condition affecting…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-04-14 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to provide eight consecutive hours of registered nurse staff on a daily basis for the residents of the facility. Findings included:- The 01/01/2026 Facility Assessment 2026, documentation included Staff/Personnel requirements, which documented:Nursing staffing consists of an equivalent of 24-hour licensed nurse coverage with at least 8 consecutive hours of Registered Nurse (RN) daily.On 04/12/26 at 09:15 AM, Licensed Nurse (LN) I confirmed there was not a Registered Nurse present in the building, and Administrative Nurse D was out of town. LN I identified herself as the only scheduled day shift nurse on location.The Daily Posting of Nursing Hours Sheet for Sunday, 04/12/26, lacked entries for RN coverage.Review of the Nursing schedule for Sunday 03/29/26 through 04/12/26 revealed a lack of scheduled RN coverage for the following dates:Monday, 03/30/26.Wednesday, 04/01/26.Monday, 04/06/26 26.Tuesday, 04/07/26.Wednesday, 04/08/26.Saturday, 04/11/26.Sunday 04/12/26. On 04/14/2026 at 02:35 PM, Administrative Nurse D…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-04-14 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 38 residents and one main kitchen. Based on observation, interviews and record review the facility failed to store, prepare and serve food in a sanitary manner. Findings included:- During the initial kitchen tour on 04/12/26 at 09:18 AM, observation revealed the following concerns: 1. Dry goods storage: One open, undated container of cumin.One open, undated container of Everything Spice.One open, undated container of honey granules.One open, undated container of thyme.One open, undated container of cinnamon.A large non-skid mat was folded over in the middle of the dry storage room.2. Freezer:A sleeve of bagels and English muffins had no label or date.The freezer doors were dirty with fingerprints, food residue, and smudges on and around the handles.3. Preparation areaA tall metal cup with no lid that contained milk sat on the preparation area.An open-to-air, undated loaf of bread sat on a shelf.4. RefrigeratorOne open but undated gallon of milk.One opened undated and unlabeled bottle of Diet Coke.The refrigerator doors were dirty with fingerprints,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-04-14 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 38 residents. Based on observation, interviews, and record review, the facility failed to ensure staff served palatable meals to the residents when the staff served dry, burnt ham to the residents on 04/12/26 for the lunch meal. Findings included:- An observation on 04/12/26 at 12:50 PM revealed residents seated in the dining room eating lunch which included ham. The ham appeared dry and dark on the residents' plates. On 04/12/26 at 12:50 PM, Resident (R) 39 stated he had no issues with his meal, except for the dry, burnt ham he was served for lunch.On 04/12/26 at 12:55 PM, R33 also stated the ham on her plate at lunch was dry and burnt. During an observation of R3 eating lunch in his room on 04/12/26 at 01:11 PM, R3 coughed extensively while eating his lunch. He took a drink of his water while chewing a piece of the dry, burnt ham. He continued to cough until tears ran down his face, and his cough was dry and unproductive. The sips of water did not appear to help and R3 turned on his call light. At 01:20 PM, Certified Nursing Assistant (CNA) M…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-14 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, observation and record review, the facility failed to ensure adequate hand hygiene during medication administration for Resident (R) 28, a tube feeding (administration of nutritionally balanced liquefied foods or nutrients through a tube) for R5, and for hands-on care for R30 and R3. Findings included:1. On 04/13/26 at 08:14 AM, Certified Medication Aide (CMA) R applied her gloves to her hands and applied a topical medication patch to R28's right shoulder. CMA R gathered an inhaler and a nasal spray container, removed her gloves, and without performing hand hygiene she took the medication keys out of her pocket, and opened the medication cart drawer, placed the items in the cart, removed another nasal spray medication bottle then handed that bottle to R28 who spayed the medication into each nostril then handed the nasal spray bottle back to CMA R who placed the bottle back into the cart and then performed hand hygiene. On 04/13/26 at 08:45 AM, CMA R reported that she realized she did not perform hand hygiene when she removed her gloves after the patch was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-14 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the physician for Resident (R) 30 was informed when the resident had refused several medications which included an antibiotic for a urinary tract infection (UTI - an infection in any part of the urinary system). Findings included:- R30's Electronic Medical Record (EMR) revealed diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), constipation (difficulty passing stools), and vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) R30's Quarterly MDS dated [DATE], which documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. R30's MDS documented he required total assistance with toileting hygiene and R30 was always continent of bowel. R30's Care Plan instructed staff to administer medications as ordered, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 38 residents. The sample included 14 residents. Based on observation, interview, and record review, the facility failed to provide dependent Resident (R) 30 with activities of daily living (ADL) services, including shaving of facial hair. Findings included:- R30's Electronic Medical Record (EMR) revealed diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain). R30's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. R30's MDS documented he required touching assistance with personal hygiene. R30's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated 04/10/25, documented R30 required assistance with some activities of daily living and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-14 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to monitor and respond to Resident (R) 30's lack of bowel movements. Findings included:- R30's Electronic Medical Record (EMR) revealed diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), constipation (difficulty passing stools), and vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain). R30's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. R30's MDS documented that he required total assistance with toileting hygiene, and he was always continent of bowel. R30's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated 04/10/25, documented R30 required assistance with some activities of daily living and would proceed to plan of care. R30's Urinary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-14 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate care and services for Resident (R) 22's peripherally inserted central catheter (PICC - a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein above the heart) when staff failed to perform the PICC dressing change every seven days. Findings included:- R22's Electronic Medical Record (EMR) included diagnosis of osteomyelitis (local or generalized infection of the bone and bone marrow) right femur (thigh bone). R22's Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition. R22's MDS documented she required total assistance with most of her activities of daily living (ADLs). R22's Functional Abilities Self-Care and Mobility Care Area Assessment (CAA), dated 11/25/25, documentedresident required increased level of assistance with ADLs related to recent fracture (broken bone) and surgical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-13 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 41 residents; the sample included four residents. Based on observation, interview, and record review, the facility failed to ensure residents remained free from significant medication errors when staff administered anti-anxiety medications (medications used to treat anxiety, which calm and relax individuals experiencing anxiety) incorrectly for Resident (R)1.Findings included:- R1's Electronic Medical Record (EMR) revealed the following diagnoses: schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R1's Annual Minimum Data Set [MDS], dated 02/26/25, documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. She received anti-anxiety medication during the assessment period. The Psychotropic Drug Use Care Area Assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-06-12 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 29 residents. Based on record review and interview, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS i.e., Payroll Base Journal (PBJ), related to licensed nursing licensed and certified nursing staffing information when the facility failed to accurately report weekend staffing for the third quarter 2023 April through June. Findings included: Review of the nursing staff schedule for the third quarter 2023 April through June, revealed lack of completed daily staff postings for May 28, 29 and 30. Review of the PBJ Staffing Data Report for the third quarter 2023, revealed the PBJ triggered for Excessively Low weekend Staffing. Interview, on 06/12/24 at 02:20 PM, with Administrative Staff A, revealed the system used in 2023 for documentation of nursing staff hour may have caused errors in reporting on the PBJ report. The facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 7 citations
- Potential for harm · Fcited before2024-06-12 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 29 residents. Based on observation, interview and record review, the facility failed ensure a plan to monitor the effectiveness of recommended measures put in place following identification of positive Legionella (a pneumonia [lung infection] bacteria found in water) detected in the facility water system in March 2024 and April 2024. In addition, the facility failed to ensure five combs and one hair brush were stored in a sanitary manner in the beauty shop. Findings included: - The CDC (Center for Disease Control) indicated the following guidelines for significance of Legionella concentrations: Well controlled growth in potable water (drinking water) detectable levels to 0.9 CFU/ml (Colony Forming Units/milliliter) and in non-potable water the detectable level is to 9 CFU/ml. Poorly controlled growth in potable water with measures of 1.0-9.9 CFU/ml and in non-potable water, the level is 10-99 CFU/ml. Uncontrolled growth in potable water greater than 10 CFU/ml in potable water and greater than 100 CFU/ml in non-potable water. Change in concentration…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-12 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 29 residents with 13 residents sampled, including five residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to ensure appropriate monitoring of psychotropic medications (a medication which affects behavior, mood, thoughts, or perception) for one Resident (R)5, regarding the use of anti-depressant medications (medications used to treat depression). Findings included: - Review of Resident (R)5's electronic medical record (EMR) revealed the following diagnoses: auditory hallucinations (when a person hears voices or noises that don't exist in reality), major depressive disorder (MDD-a major mood disorder) and psychosis (any major mental disorder characterized by a gross impairment in reality perception). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. She received anti-depressant medications (medications used to treat…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-30 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility census totaled 36 residents, with 12 sampled, including five residents sampled for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure adequate follow-up of the consultant pharmacist recommendations regarding Depakote (anti-convulsant medication, sometimes used for the manic episodes associated with bipolar) for Resident (R) 10, regarding decreasing the dose of this medication. This failure placed the resident at risk for adverse effects related to medication use. Findings Included: - R10's 11/29/22 Electronic Health Record (EHR), documented diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and major depressive disorder (major mood disorder). The 07/15/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 99, and per staff R10 had long and short-term memory problems which indicated moderately impaired cognition. The assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-30 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility census totaled 36 residents, with 12 sampled, including five residents sampled for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure reduction in Depakote (anti-convulsant medication, sometimes used for the manic episodes associated with bipolar) for Resident (R) 10, by not decreasing the medication as ordered. This failure placed the resident at risk for adverse effects related to medication use. Findings Included: - R10's 11/29/22 Electronic Health Record (EHR), documented diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and major depressive disorder (major mood disorder). The 07/15/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 99, and per staff R10 had long and short-term memory problems which indicated moderately impaired cognition. The assessment documented the use of an antidepressant and diuretic medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2026-04-14 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to accurately post daily nurse staffing information for Registered Nurses, Licensed Practical Nurses, Certified Nurse Aides, the resident census, and the total number of scheduled hours and actual hours worked by each category for each shift, as required. Findings included:- On 04/12/26 at 09:15 AM, entering the facility, Licensed Nurse (LN) I reported the census of 38 residents and verified she was the charge nurse on duty. The Daily Posting of Nursing Hours Sheet, for Sunday, 04/12/26, documentation included a census of 44 residents and lacked entries for total scheduled hours for all categories of nursing staff. Review of the Daily Posting of Nursing Hours Sheet for 04/2025 through 04/12/26 documentation revealed a daily census of 44 residents and lacked entries for total scheduled hours for each shift by all categories of nursing staff. On 04/14/2026 2:40 PM, Administrative Staff A confirmed the census of 38 residents and the lack of total hours for each shift and category of nursing staff. She reported that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2026-04-14 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
The facility reported a census of 38 residents. Based on observations, interview, and record review, the facility failed to maintain and/or dispose of kitchen garbage and refuse properly. Findings included: - During a tour of the kitchen on 04/13/26 at 04:35 PM, observation revealed the outside garbage receptacle had three of six lids open. During an interview on 04/13/26 at 04:38 PM, Maintenance U stated the lids are always flying open due to the strong winds and they are supposed to be closed. During an interview on 04/13/26 at 04:45 PM, Administrative Nurse D reported staff are always outside closing the lids to the garbage bins, but the wind is a significant issue. Administrative Staff A stated she was aware of the issue with the garbage receptacle lids, but people eat their lunch in the back of the facility during the day, but the lids should be closed. The facility's policy Food-Related Garbage and Rubbish Disposal, dated 10/2025, states all garbage containers will have tight-fitting and must be kept covered when not in continuous use.
- No harm found · Ccited before2026-04-14 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to electronically submit complete and accurate staffing information through Payroll-Based Journaling (PBJ) related to weekend staffing. Findings included: - The PBJ Staffing Data Report revealed low weekend staffing for the following timeframes:Fiscal Year (FY) 2025, Quarter (Q) 2 (January 1 - March 31)FY 2025 Q3 (April 1 - June 30)FY 2025 Q4 (July 1 - September 30)FY 2026 Q1 (October 1 - December 31, 2025). On 04/14/2026 at 02:35 PM, Administrative Nurse D confirmed the inaccuracies of the PBJ data for the quarters identified above and stated she often worked the weekend as the RN on duty and said Administrative Nurse E works the weekends as well occasionally but she does not know if that time was accurately reported and reflected in the PBJ reports above quarters. On 04/14/2026 at 2:40 PM, Administrative Staff A reviewed the PBJ data submitted and confirmed the above noted reports flagged for low weekend staffing although she did not feel the report was accurate, due to the staffing they provided was consistent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$11,911 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $11,911 — penalty dated 2024-07-15
- Medicare payment denial — starting 2024-07-31 for 51 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to MISSION HEALTH COMMUNITIES — 30 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.8 | +0.2 vs chain |
| Health inspection | 3 of 5 | 2.9 | +0.1 vs chain |
| Staffing | 4 of 5 | 2.9 | +1.1 vs chain |
| Quality measures | 2 of 5 | 2.9 | -0.9 vs chain |
The other 29 homes this chain runs (chain average 2.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CORONADO OPERATOR, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 10/01/2019 |
| BARRES, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/01/2019 |
| CURIS HOLDINGS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/01/2019 |
| T AND C CAPITAL ASSETS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/01/2019 |
| WINDWARD HEALTH PARTNERS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/01/2019 |
| YOAKUM, JAMIE | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 03/19/2024 |
| MISSION HEALTH COMMUNITIES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2019 |
| NEODESHA OPERATOR, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2019 |
| LINDEMAN, STUART | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2019 |
| THOMAS, TINA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2019 |
CMS files one row per role, so the 11 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
7 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 81% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $214K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in KS
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Kansas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175317. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-14, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.