Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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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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 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 | — | 0 | 0 |
| Montgomery Place Nursing Center | 15 mi | — | 0 | 0 |
| Diversicare Of Chanute | 20.2 mi | — | 19 | 0 |
| Heritage Health Care Center | 20.5 mi | — | 2 | 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 August 2026) and official state health department websites.