Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Neodesha Care And Rehab during CMS and state inspections, most recent first.
Lack of Scheduled RN Coverage: The facility failed to provide 8 consecutive hours of RN coverage daily. The staffing schedule and daily nursing hours posting showed no RN coverage on multiple days, and an LPN confirmed no RN was present in the building while she was the only scheduled day shift nurse on site. The DON stated she and another administrative nurse sometimes covered weekends, but neither was listed on the schedule or staff postings and there was no auditable evidence of the RN coverage.
Food was not stored, prepared, or served in a sanitary manner in the kitchen. Surveyors observed multiple open and undated dry goods, an unlabeled sleeve of bagels and English muffins in the freezer, uncovered milk in the prep area, an open undated loaf of bread, an open undated gallon of milk, and an opened undated unlabeled bottle of Diet Coke. The freezer and refrigerator doors, steam table shelf, and handwashing sink were also dirty with residue and smudges, and dietary staff stated food items are supposed to be dated.
Palatable Meal Service Failure: Residents were served dry, burnt ham at lunch, and two residents said the ham was dry and burnt. One resident eating in his room coughed extensively while trying to eat the ham, drank water while chewing, and continued coughing until tears ran down his face before using his call light. A CNA later noted residents had complained the ham was dry and hard to eat, and dietary staff said the ham was overcooked and dry but was served anyway.
Failure to perform hand hygiene occurred during med pass, tube feeding care, and hands-on resident care. A CMA removed gloves and handled meds without sanitizing, an RN and CNA used the same gloves for incontinent care and breakfast setup, an LPN continued tube feeding tasks after glove changes without hand hygiene, and CNAs provided catheter care and oral care with the same gloves after dirty tasks. Facility policy stated hand hygiene is required after glove removal and when moving from contaminated to clean tasks.
Failure to Notify Physician of Medication Refusals: A resident with DM, constipation, and vascular dementia repeatedly refused Macrobid for a UTI and other meds, but the EMAR and progress notes lacked documentation that the provider was notified. Staff interviews showed inconsistent practices about when to update the provider, and the facility policy required documentation of the refusal and physician notification.
A resident with DM and vascular dementia, who required assistance with personal hygiene, did not receive consistent ADL support for grooming, including shaving of facial hair. Shower records showed multiple showers were offered, but shaving was documented only twice, and the resident was observed with stubbly facial hair after showering and said she had asked for it to be removed. CNA and nursing staff stated dependent residents were expected to receive shaving assistance on shower days and as needed.
A resident with DM, constipation, and vascular dementia went more than 72 hours without a BM on two separate occasions, each lasting six consecutive days, before any response was documented. The resident had orders for Colace and PRN bisacodyl, but EMR notes show PRN Milk of Magnesia was offered only after the prolonged no-BM periods, with the resident refusing medication and prune juice on one occasion and later receiving Milk of Magnesia on another. Staff interviews stated the charge nurse was responsible for reviewing the 72-hour no-BM report, offering PRN meds, completing an abdominal assessment, and notifying the provider if no BM occurred for several days.
PICC Dressing Change Not Performed Weekly: A resident with a PICC for IV antibiotics and osteomyelitis had a dressing that remained dated and peeling up beyond the weekly interval. The chart lacked a physician order for weekly PICC dressing changes, and staff observed the dressing still in place while an LPN noted it needed to be changed and that PICC dressings are changed every 7 days and as needed by an RN.
Inaccurate daily nurse staffing posting. A charge nurse reported a census of 38 residents, but the daily staffing sheet listed 44 residents and did not include total scheduled hours for RN, LPN, and CNA staff. Review of prior staffing sheets showed the same census and continued missing scheduled-hour entries, and an admin staff member confirmed the omissions and stated the actual hours were only revised at the end of the day.
Improper Garbage Receptacle Lid Management: Surveyors observed the outside garbage receptacle with 3 of 6 lids open. Maintenance staff said strong winds kept the lids flying open, and an RN reported staff were repeatedly going outside to close them. Admin staff acknowledged the issue, and the facility policy required all garbage containers to have tight-fitting lids and remain covered when not in continuous use.
Inaccurate PBJ Weekend Staffing Submissions: The facility failed to submit complete and accurate PBJ direct care staffing data, with reports flagging low weekend staffing across multiple quarters. An Administrative Nurse confirmed the inaccuracies and stated she often worked weekends as the RN on duty, while another Administrative Nurse also worked weekends occasionally, but it was unclear whether that time was accurately reported. Administrative Staff reviewed the submitted data and said the weekend staffing appeared consistent with weekday staffing, though the facility continued to be flagged for low weekend staffing.
A resident with schizophrenia and anxiety, identified as at risk for psychotropic side effects, had physician orders for lorazepam 1 mg PO at HS and 0.5 mg PO BID. During a morning med pass, a CMA administered the 1 mg HS lorazepam dose instead of the ordered 0.5 mg morning dose and did not verify the MAR and medication card twice before administration. The error was not identified until another staff member prepared the afternoon lorazepam dose, revealing that the medication had not been given according to the physician’s orders.
The facility failed to submit accurate staffing data to CMS for the third quarter of 2023, particularly for weekends. Missing daily staff postings for specific dates led to a PBJ report indicating excessively low weekend staffing. An administrative staff member noted potential errors due to a new reporting system used without an established policy.
The facility failed to monitor the effectiveness of measures for Legionella bacteria control in the water system, with poorly controlled growth detected in several areas. Additionally, the beauty shop lacked sanitary storage for personal care items, with unlabeled and unsanitized brushes and combs found. The facility did not have a policy for sanitizing and storing these items, leading to potential cross-contamination.
A facility failed to monitor the use of anti-depressant medications for a resident with major depressive disorder and psychosis. Despite the care plan's instructions, there was no documentation of monitoring for side effects or effectiveness. An administrative nurse confirmed this oversight, which violated the facility's policy on psychotropic drug use.
Lack of Scheduled RN Coverage
Penalty
Summary
The facility failed to provide eight consecutive hours of RN staffing on a daily basis. The 01/01/2026 Facility Assessment documented that nursing staffing consisted of 24-hour licensed nurse coverage with at least 8 consecutive hours of RN coverage daily, but the Daily Posting of Nursing Hours Sheet for Sunday, 04/12/26 had no RN entries. On 04/12/26 at 09:15 AM, a Licensed Nurse confirmed there was no RN present in the building and stated she was the only scheduled day shift nurse on site, while Administrative Nurse D was out of town. Review of the nursing schedule for 03/29/26 through 04/12/26 showed no scheduled RN coverage on multiple dates, including 03/30/26, 04/01/26, 04/06/26, 04/07/26, 04/08/26, 04/11/26, and 04/12/26. On 04/14/2026, Administrative Nurse D confirmed the lack of scheduled RN coverage and stated she often worked weekends as the RN on duty for eight consecutive hours, but there was no auditable or verifiable evidence of her doing so and she was not listed on the schedule or staff postings. She also stated Administrative Nurse E sometimes worked weekends to cover the daily RN requirement, but she was not identified on the schedule either.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in a sanitary manner in the facility’s main kitchen serving a census of 38 residents. During the kitchen tour, surveyors observed multiple open, undated food items in dry storage, including containers of cumin, Everything Spice, honey granules, thyme, and cinnamon, along with a folded non-skid mat in the dry storage room. In the freezer, a sleeve of bagels and English muffins had no label or date, and the freezer doors had fingerprints, food residue, and smudges on and around the handles. In the preparation area, a tall metal cup containing milk sat uncovered, and an open-to-air, undated loaf of bread was on a shelf. In the refrigerator, there was an open but undated gallon of milk and an opened, undated, unlabeled bottle of Diet Coke, and the refrigerator doors were dirty with fingerprints, food residue, and smudges on and around the handles. In the general kitchen area, an open-to-air, undated box of cereal was on a table near the dishwashing area, the lower shelf under the steam table was dirty with crumbs, dried liquid, and sticky residue, and the handwashing sink had dried brown and gray areas on the front and back. Dietary staff stated that items are supposed to be dated, and a dietary staff member stated it was her expectation that food items be dated upon arrival and when opened.
Palatable Meal Service Failure
Penalty
Summary
The facility failed to ensure staff served palatable meals when residents were given dry, burnt ham at lunch. During observation of the dining room, residents were seen eating lunch that included ham, and the ham on their plates appeared dry and dark. Two residents stated the ham they received was dry and burnt, and one resident eating in his room coughed extensively while trying to eat the dry, burnt ham, drank water while chewing, continued coughing until tears ran down his face, and then activated his call light. A CNA responded to the resident’s call and noted that residents had complained the ham was dry and hard to eat that day. The CNA took the resident’s lunch tray back toward the kitchen. Dietary staff later stated the ham was overcooked and dry but that she served it anyway. The Administrator stated she expected staff to serve food that was cooked properly and palatable, and Administrative Staff A reported the ham was served because Dietary Staff BB was worried she would be in trouble if she did not follow the menu during the survey. The facility’s Food Preparation and Service policy stated residents are provided with meals that are palatable and attractive.
Failure to Perform Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to ensure adequate hand hygiene during medication administration, tube feeding care, and hands-on resident care. During medication administration for one resident, a CMA applied a topical patch, removed gloves, and then handled medication keys, opened the medication cart, and gave a nasal spray without performing hand hygiene after glove removal. The CMA later stated she realized she did not sanitize her hands after removing the gloves and said she should have done so. During incontinent care for another resident, an Administrative Nurse and a CNA assisted the resident to the bathroom. The CNA removed soiled brief and pants and bagged them, while the Administrative Nurse applied wheelchair foot pedals that had been on the bathroom floor and then, using the same gloves, performed peri-care. The CNA kept the same gloves on after removing the soiled brief and pants and later used those gloves to set up the resident’s breakfast tray, including applying a neck napkin, unrolling silverware, and opening a fruit cup. Both staff later stated they should have removed gloves and performed hand hygiene before continuing care, especially before food setup. During tube feeding care for a resident with a feeding tube, a Licensed Nurse aspirated stomach contents, then removed one glove and, without hand hygiene, retrieved a new glove and continued with pH testing and feeding administration. During catheter care for another resident, a CNA emptied the catheter bag, removed gloves, and applied new gloves without hand hygiene, then continued with cleansing, transfer assistance, oral care setup, and face care using the same gloves. The CNA also handled a walkie talkie during the care sequence. Facility leadership stated staff were expected to perform hand hygiene after glove removal and when moving from dirty to clean tasks, and the facility policy stated gloves do not replace hand hygiene.
Failure to Notify Physician of Medication Refusals
Penalty
Summary
The facility failed to ensure the physician was informed when Resident 30 refused several medications, including Macrobid prescribed for a UTI. Resident 30 had diagnoses of DM, constipation, and vascular dementia, with a BIMS score of 10 indicating moderately impaired cognition. The care plan directed staff to administer medications as ordered and monitor/document side effects and effectiveness. The EMAR documented refusals of Macrobid on multiple occasions, but the record lacked documentation that a provider was updated, and the progress notes from the same period also lacked documentation that the provider was notified of the refusals. Staff interviews showed inconsistent understanding of when the provider should be notified after medication refusal. One nurse reported that staff would let the charge nurse know and generally wait until the provider came for weekly rounds, while another stated she might text the provider from her phone. The facility provider reported being notified on 03/31/26 that Resident 30 was refusing most medications and discussed palliative care with the resident's DPOA and the Administrative Nurse after the antibiotic course. Administrative Nurse D stated that whether a provider should be updated depended on the type of medication refused, and also stated the resident should be educated when medication is refused. The facility policy required staff to interview the resident about the refusal and document the date and time of the attempt, the physician notification, and the physician's response.
Failure to Provide ADL Assistance and Facial Hair Shaving
Penalty
Summary
The facility failed to provide dependent Resident 30 with activities of daily living services, including shaving of facial hair. Resident 30 had diagnoses of diabetes mellitus and vascular dementia. The resident’s MDS assessments documented a BIMS score of 13 on the annual assessment and later a BIMS score of 10 on the quarterly assessment, with the quarterly assessment indicating moderate cognitive impairment and need for moderate assistance with personal hygiene. The care plan documented that staff were to provide setup assistance for personal hygiene tasks and that the resident could ask for help if needed. Review of shower sheets from 03/09/26 through 04/13/26 showed 15 showers were offered, but the resident was shaved on only two days. On 04/13/26, the resident was observed after showering with approximately 1/8 inch of stubbly white facial hair on the chin and reported that she had asked for it to be removed. CNA O stated that facial hair would be removed during showers for residents who could not shave themselves and that Resident 30 could not shave her facial hair and refused at times. LN H stated staff were expected to remove facial hair for residents needing assistance with personal hygiene on scheduled shower days and as needed. Administrative Nurse E stated staff were expected to offer shaves and nail care to dependent residents on shower days and as needed. The facility policy stated dependent residents would receive care and services to maintain grooming and personal and oral hygiene.
Failure to Monitor and Respond to Constipation
Penalty
Summary
The facility failed to monitor and respond to a resident’s lack of bowel movements. The resident had diagnoses including DM, constipation, and vascular dementia. The EMR documented a BIMS score of 13 on the annual MDS and 10 on the quarterly MDS, with the resident requiring total assistance with toileting hygiene and being always continent of bowel. The care plan documented monitoring for possible adverse drug reaction signs and symptoms, including constipation, but the later care plan lacked documentation regarding the constipation diagnosis and staff instructions. Physician orders included Colace 100 mg twice daily for constipation and bisacodyl suppository 10 mg every 24 hours as needed for constipation. Review of bowel movement records showed the resident went more than 72 hours without a bowel movement from 03/17/26 through 03/22/26, a total of six consecutive days, with no response until 03/22/26. The resident again went more than 72 hours without a bowel movement from 03/29/26 through 04/03/26, another six consecutive days, with no response until 04/04/26. EMAR notes documented Milk of Magnesia was offered on 03/22/26 and 03/23/26 because the resident was on the no bowel movement list, but the resident refused medication and prune juice and had no abdominal pain or discomfort, with bowel sounds present. On 04/04/26, Milk of Magnesia was administered as needed for no bowel movement. Provider notes during the period documented a soft abdomen and normal bowel sounds. Staff interviews indicated the charge nurse was responsible for reviewing the 72-hour no bowel movement report, offering PRN medication, completing an abdominal assessment, and updating the provider if the resident had not had a bowel movement for several days. The facility policy lacked documentation of monitoring bowel movements and management of constipation.
PICC Dressing Change Not Performed Weekly
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids when needed was not met for a resident with osteomyelitis of the right femur who had a PICC line for IV antibiotics. The resident’s records showed intact cognition with a BIMS score of 14 and dependence for most ADLs. Her care plan instructed staff to change the PICC dressing weekly per order, but the physician orders in the record lacked an order for weekly PICC dressing changes. The facility’s documentation showed the PICC dressing was changed on 03/16/26 and again on 03/29/26 because the dressing was peeling up, with redness noted at the insertion site on 03/29/26. On 04/12/26 and again on 04/13/26, the PICC dressing on the resident’s right upper arm was observed dated 04/05/26 and peeling up. The resident reported she was receiving an IV antibiotic and could not remember whether staff changed the dressing every week. A licensed nurse assessed the dressing on 04/13/26 and stated it needed to be changed because it was peeling up, and reported that PICC dressings are changed every seven days and as needed by an RN. The nurse also stated the resident did not have a physician order for PICC dressing changes, so it would not appear on the EMAR to alert staff. Administrative nursing staff stated they expected the nurse to complete a dressing change every seven days and as needed, and expected all residents with PICC lines to have an order for PICC dressing changes. The facility policy required sterile dressing changes at least weekly or if the dressing integrity had been compromised.
Inaccurate Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to accurately post daily nurse staffing information, including the census, the total number of scheduled hours, and the actual hours worked by Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides for each shift. On 04/12/26 at 09:15 AM, a Licensed Nurse reported a census of 38 residents and confirmed she was the charge nurse on duty, but the Daily Posting of Nursing Hours Sheet for that day listed a census of 44 residents and did not include total scheduled hours for all nursing staff categories. Review of the Daily Posting of Nursing Hours Sheet for 04/2025 through 04/12/26 showed the same census of 44 residents and continued to lack total scheduled hours for each shift by all categories of nursing staff. On 04/14/2026 at 2:40 PM, Administrative Staff A confirmed the census of 38 residents and the missing total hours for each shift and category, and stated that another form had been created for posting daily hours but the scheduled hours were not understood to be required and the actual hours were not revised on the daily posting until the end of the day.
Improper Garbage Receptacle Lid Management
Penalty
Summary
The facility failed to maintain and dispose of kitchen garbage and refuse properly. During a tour of the kitchen, surveyors observed the outside garbage receptacle with three of six lids open. Maintenance U stated the lids are always flying open because of strong winds and that they are supposed to be closed. 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 and noted that 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 lids and must be kept covered when not in continuous use.
Inaccurate PBJ Weekend Staffing Submissions
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information through Payroll-Based Journaling (PBJ) based on payroll and other verifiable and auditable data. The PBJ Staffing Data Report showed low weekend staffing for FY 2025 Q2, Q3, and Q4, as well as FY 2026 Q1. The report identified inaccuracies related to weekend staffing submissions for those quarters. On 04/14/2026, Administrative Nurse D confirmed the PBJ data inaccuracies and stated she often worked weekends as the RN on duty, while Administrative Nurse E also worked weekends occasionally, but she did not know whether that time was accurately reported in the PBJ reports. Administrative Staff A reviewed the submitted PBJ data and confirmed the reports were flagged for low weekend staffing, although she believed the staffing provided was consistent with weekday staffing with few weekend exceptions. She stated she had been told the low weekend staffing issue was a coding problem at the corporate level and thought it had been resolved, but the facility continued to be flagged. The facility policy on Payroll Based Journal F851, dated 04/2026, stated the community would submit payroll data in a uniform format to CMS including staffing information for community, agency, and contract staff, including the category of work for each direct care staff member.
Incorrect Lorazepam Dose Administered Due to Failure to Verify MAR
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident remained free from significant medication errors when anti-anxiety medication was administered incorrectly. The resident had diagnoses of schizophrenia and anxiety, with MDS assessments showing initially intact cognition followed by moderately impaired cognition, and was identified as being at risk for side effects related to psychotropic medications. The resident’s care plan directed staff to monitor for adverse side effects from psychotropic drugs. Physician orders in the EMR specified lorazepam 1 mg PO at bedtime and lorazepam 0.5 mg PO twice daily for anxiety. On a morning medication pass, the Medication Administration Record documented that the resident received 1 mg of lorazepam at 08:00 instead of the ordered 0.5 mg morning dose. The facility’s investigation determined that the Certified Medication Aide administered the nighttime 1 mg dose in place of the ordered 0.5 mg morning dose and did not discover the error until another staff member prepared the afternoon lorazepam dose several hours later. The CMA later confirmed she had given the wrong dose and stated she had not checked the MAR and the medication card twice before administering the medication. The facility’s psychotropic drug policy required medications to be given according to the physician’s orders, which did not occur in this instance.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the third quarter of 2023, specifically from April through June. The deficiency was identified when the facility did not accurately report weekend staffing, as evidenced by missing daily staff postings for May 28, 29, and 30. The Payroll Based Journal (PBJ) Staffing Data Report for the same period triggered for excessively low weekend staffing. An interview with Administrative Staff A revealed that the system used in 2023 for documenting nursing staff hours may have caused errors in the PBJ report. Additionally, the facility had implemented a new reporting system without an established policy for its use in 2023.
Deficiencies in Legionella Monitoring and Beauty Shop Sanitation
Penalty
Summary
The facility failed to implement a plan to monitor the effectiveness of measures put in place after detecting positive Legionella bacteria in the water system. Initial testing in February 2024 revealed poorly controlled growth of Legionella in the therapy room, whirlpool, and kitchen sink. Subsequent testing in March 2024 showed uncontrolled growth in the shower room and well-controlled growth in the water heater. Despite recommendations from the testing company to adjust water heater temperatures and conduct follow-up testing, the facility did not retest the water until June 2024. Additionally, the facility did not ensure sanitary storage of personal care items in the beauty shop. During an environmental tour, an unlabeled hairbrush and five unlabeled combs with hair in them were found. Maintenance staff confirmed the lack of sanitation and labeling, and it was unclear who was responsible for maintaining the beauty shop's hygiene. The facility had identified the need to clean the beauty shop cabinets in May 2024 but had not implemented the plan. The facility lacked a policy to address the sanitization, labeling, and storage of personal hygiene items in the beauty shop, leading to potential cross-contamination and infection spread. Administrative staff acknowledged the expectation for staff to sanitize and store items properly but had not assigned responsibility for maintaining the beauty shop's cleanliness.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure appropriate monitoring of psychotropic medications for a resident diagnosed with auditory hallucinations, major depressive disorder, and psychosis. The resident's electronic medical record indicated the use of multiple anti-depressant medications, including Bupropion, Wellbutrin, and Effexor, prescribed for major depressive disorder with psychotic symptoms. Despite the care plan's instructions to monitor for side effects and effectiveness of these medications, the resident's records lacked documentation of such monitoring. An interview with Administrative Nurse D confirmed the absence of monitoring for the anti-depressant medications. The facility's policy on Psychotropic Drug Use, revised in April 2024, mandates staff to review each resident's medication regime and initiate appropriate monitoring for each drug classification, including targeted behaviors. However, this policy was not adhered to, resulting in a deficiency in monitoring the resident's anti-depressant medication use.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Neodesha
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medicalodges Independence | 13.1 mi | ★★★★★ | 0 | 0 |
| Advena Living Of Cherryvale | 13.1 mi | ★★★★★ | 24 | 0 |
| Montgomery Place Nursing Center | 15 mi | ★★★★★ | 0 | 0 |
| Diversicare Of Chanute | 20.2 mi | ★★★★★ | 19 | 0 |
| Heritage Health Care Center | 20.5 mi | ★★★★★ | 8 | 0 |
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