Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Medicalodges Neosho during CMS and state inspections, most recent first.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
The facility failed to develop and implement comprehensive care plans for four residents that addressed side rail usage. Despite having side rails or grab bars in use, the care plans did not include these details, contrary to facility policy. Interviews with staff confirmed that side rails should be included in care plans, but there was uncertainty about grab bars and quarter rails.
The facility failed to promote self-determination for a resident who requested a room change due to conflicts with their roommate. Despite repeated requests and documented conflicts, the facility moved the resident back into the same room multiple times, leading to a hostile living environment. Staff and responsible parties were aware of the issues, but the facility prioritized room availability and financial constraints over the resident's well-being.
A resident with moderate cognitive impairment fell and reported significant hip pain. The night nurse did not immediately notify the physician or responsible party, delaying notification by over six hours. The resident was eventually sent to the hospital the following morning after further assessment by the ADON and day nurse.
The facility failed to ensure a clean and homelike environment when staff did not properly clean and maintain a resident's toilet riser, which had layers of curling duct tape and a brown fecal-like substance. Housekeeping staff were aware but unable to clean it properly due to the resident's refusal to allow changes to the duct tape and plastic sheeting.
The facility failed to notify and coordinate with the State-designated authority for a PASARR Level II evaluation after a resident was diagnosed with schizophrenia and cognitive communication deficit. Staff misunderstood PASARR requirements, leading to the omission.
A resident fell and complained of significant pain and decreased mobility in his left hip/leg. The night nurse did not immediately notify the physician or responsible party, resulting in a delay in the resident receiving appropriate medical evaluation and treatment for a fractured femur. The resident was only sent to the emergency room after the day shift nurse arrived and assessed the situation.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Include Side Rail Usage in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents that addressed side rail usage. Resident #5, diagnosed with Alzheimer's disease, had a raised u-shaped grab bar on the right side of the bed, but the use of side rails/u-shaped grab bar was not included in the care plan. Resident #12, with diagnoses including cognitive communication deficit and delusional disorders, had bilateral quarter side rails in raised position, but the care plan did not address the use of side rails. The resident used the side rails for bed mobility and had them put on after falling out of bed. Resident #26, diagnosed with Parkinson's disease, schizoaffective disorder, and unspecified dementia, had bilateral u-shaped grab bars in raised position on the bed, but the care plan did not address the use of side rails. The resident did not use the grab bars. Resident #47, with diagnoses including cognitive communication deficit and presence of left artificial hip joint, had a u-shaped grab bar in raised position on the left side of the bed, but the care plan did not address the use of side rails. The resident used the grab bar for transfer and bed mobility. Interviews with staff, including an LPN, the MDS Coordinator, the DON, and the Administrator, confirmed that side rails should be included in the care plans. However, there was uncertainty about whether grab bars and quarter rails should be included. The facility's policies on electronic care plans and side rail use and assessment were not followed, leading to the deficiency in care planning for side rail usage.
Failure to Promote Resident Self-Determination
Penalty
Summary
The facility failed to promote self-determination for Resident #27, who requested a room change due to conflicts with their roommate, Resident #39. Despite the resident's repeated requests and documented conflicts, the facility moved Resident #27 back into the same room with Resident #39 multiple times. The conflicts included verbal altercations over room temperature, television volume, and other issues, leading to a hostile living environment for both residents. Resident #27, who was cognitively intact and had a history of depression, expressed dissatisfaction with the living arrangement and reported daily arguments with Resident #39. The resident's care plan noted mood and behavior issues, but no significant behavioral symptoms were recorded in the most recent MDS. Despite these documented issues, the facility's staff, including the DON, decided to keep the residents together, citing reasons such as room availability and the residents' inability to afford private rooms. Interviews with staff, including LPNs and CNAs, confirmed that the residents frequently argued and sometimes cursed at each other. The DON and Administrator were aware of the conflicts but believed the residents would eventually get along. The decision to keep the residents together was also influenced by the responsible parties' input, who were informed about the situation but did not necessarily agree with the facility's plan. The facility's actions failed to honor the resident's right to self-determination and a dignified existence, as outlined in their own Resident Rights policy.
Failure to Immediately Notify Physician and Responsible Party of Resident Fall with Injury
Penalty
Summary
The facility failed to immediately notify the physician and responsible party of a fall with injury for a resident. The resident, who had moderate cognitive impairment and was able to ambulate without an assistive device, fell and reported significant pain in the left hip. Despite the resident's refusal to go to the emergency room, the staff did not notify the physician or the responsible party immediately after the fall, as required by the facility's policy. The notification to the responsible party was delayed by over six hours, and there was no documentation of physician notification until after the resident was sent to the hospital the following morning. The night nurse, who was responsible for the initial assessment, did not contact the on-call RN or the physician immediately after the fall. Instead, the nurse administered Tylenol and noted some improvement in the resident's pain but did not take further action to ensure the resident received appropriate medical evaluation. The nurse also failed to document the immediate notification of the physician and responsible party, which is a critical step in the facility's falls management protocol. The Assistant Director of Nursing (ADON) was not informed of the fall until approximately 6:00 A.M. via a text message that did not include the resident's name. Upon arriving at the facility, the ADON and the day nurse assessed the resident and determined that the resident needed to go to the hospital. The responsible party was then notified, and the resident was transported to the emergency room. The delay in notifying the physician and responsible party, as well as the failure to follow the facility's protocol for immediate notification, contributed to the deficiency identified in the report.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a clean and homelike environment for all residents when staff did not properly clean and maintain the toilet riser in one resident's bathroom. Observations revealed that the toilet riser had six layers of curling non-adhered duct tape and a brown fecal-like substance on and around the duct tape. Additionally, a clear sheet of plastic attached to the riser was found with a brown fecal-like substance and was falling into the toilet bowl water. The resident's care plan indicated that the resident had intact cognitive skills and was independent with decision-making but required staff assistance with activities of daily living due to limitations. Interviews with housekeeping staff revealed that they were aware of the issue but were unable to clean the riser properly because the resident would not allow them to change the duct tape or plastic sheeting. The Housekeeping Supervisor and the Administrator were also aware of the situation, with the Administrator having spoken to the resident multiple times about the need for regular changes to the duct tape and plastic. Despite these efforts, the resident remained unresponsive to the requests, leading to the deficiency in maintaining a clean and homelike environment.
Failure to Coordinate PASARR Level II Evaluation
Penalty
Summary
The facility failed to notify and coordinate with the State-designated authority following the newly evident or serious mental illness of a resident. Specifically, the facility did not refer Resident #51 for a PASARR Level II evaluation after the resident was diagnosed with schizophrenia and cognitive communication deficit shortly after admission. The initial PASARR Level I screening, conducted prior to admission, did not indicate any signs of major mental disorder, and the facility did not have a policy regarding PASARR requirements. The resident's medical record showed that staff did not refer the resident for additional PASARR review after the significant change in status. Interviews with facility staff revealed a lack of understanding and proper procedure regarding PASARR requirements. The Business Office Manager, Infection Control Nurse, and Director of Nursing all indicated that the PASARR Level I screening was only resubmitted if the resident had Medicaid as a payor source. The Administrator admitted to being unfamiliar with PASARR screening requirements until the current certification survey. The failure to resubmit the PASARR Level I screen for further determination was due to the resident's schizophrenia diagnosis and increased level of care needs, which should have been completed regardless of the resident's payor source.
Failure to Timely Notify Physician and Responsible Party After Resident Fall
Penalty
Summary
The facility failed to timely notify the physician, responsible party, and registered nurse on-call of a fall for one resident who complained of pain and decreased mobility to his left hip/leg. This potentially contributed to a delay in the treatment of the resident's fractured femur. The resident was found on the floor by a CNA, and despite expressing significant pain, the resident was not immediately sent to the emergency room. The resident refused to go to the hospital multiple times, and the nurse did not contact the physician or responsible party immediately after the fall, as required by the facility's policy. The resident's fall note indicated that the resident was in pain and unable to bear weight on his left leg. Despite this, the nurse only administered Tylenol and observed the resident for over an hour before assisting him back to his room. The nurse did not notify the physician or the responsible party immediately, instead planning to contact them at a more appropriate time. The resident's condition did not improve significantly, and it was only after the day shift nurse arrived that the resident was sent to the emergency room for evaluation. Interviews with the staff revealed that the night nurse did not follow the proper protocol for notifying the physician and responsible party. The Director of Nursing and the Assistant Director of Nursing confirmed that the night nurse should have contacted the on-call RN and the resident's physician immediately after the fall. The facility's failure to follow its own policy resulted in a delay in the resident receiving appropriate medical evaluation and treatment for his fractured femur.
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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.
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Nursing homes near Neosho
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Granby House | 9.7 mi | ★★★★★ | 0 | 0 |
| Mcdonald County Living Center | 12.8 mi | ★★★★★ | 0 | 0 |
| Seneca Nursing | 12.8 mi | ★★★★★ | 9 | 0 |
| Nhc Healthcare, Joplin | 16.7 mi | ★★★★★ | 0 | 0 |
| Joplin Gardens | 18 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.