Cycle 1
Health 2025-05-08 · Fire 2025-05-08
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Hillsboro, OH
Hillsboro Post Acute
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1141 Northview Drive, Hillsboro, OH
(937) 393-5766
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
67
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Legacy Health Services
Operator or chain grouping
Approved since
1984-02-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 3 overall / 3 health / 2 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.54
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.11
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.98
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.63
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.65
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.16
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.23
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
3.01
CMS adjusted total nurse staffing hours
Case-mix index
1.65
Higher values indicate more complex resident acuity
RN turnover
70%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,878
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.91
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.97
Baseline 18.24% · Performance 20.98% · Measure score 0.97 · Achievement 0.97 · Improvement 0
Healthcare-associated infections
1.46
Baseline 6.43% · Performance 7.40% · Measure score 1.46 · Achievement 1.46 · Improvement 0
Total nurse turnover
2.88
Baseline 48.28% · Performance 51.90% · Measure score 2.88 · Achievement 2.88 · Improvement 0
Adjusted total nurse staffing
0.66
Baseline 3.44 hours · Performance 3.26 hours · Measure score 0.66 · Achievement 0.66 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.9% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 69 · Observed rate 8.7% · Lower 95% interval 6.65% |
| Discharge to community | 54.59% |
50.57%
4 pts better
|
No Different than the National Rate · Eligible stays 59 · Observed rate 49.15% · Lower 95% interval 43.28% |
| Medicare spending per beneficiary | 1.32 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 97.37% |
95.27%
2.1 pts better
|
Numerator 37 · Denominator 38 |
| Falls with major injury | 5.26% |
0.77%
4.5 pts worse
|
Numerator 2 · Denominator 38 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 13 · Denominator 26 |
| Discharge mobility score | 57.69% |
50.94%
6.8 pts better
|
Numerator 15 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 7.89% |
2.29%
5.6 pts worse
|
Numerator 3 · Denominator 38 · Adjusted rate 6.68% |
| Healthcare-associated infections requiring hospitalization | 7.4% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 56 · Observed rate 8.93% · Lower 95% interval 4.32% |
| Staff COVID-19 vaccination coverage | 2.5% |
8.2%
5.7 pts worse
|
Numerator 2 · Denominator 80 |
| Staff flu vaccination coverage | 3.33% |
42%
38.7 pts worse
|
Numerator 3 · Denominator 90 |
| Discharge function score | 69.23% |
56.45%
12.8 pts better
|
Numerator 18 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.8
0.8 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.8
0.3 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
92.4%
5.9 pts better
|
93.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 96.8% · Q4 96.4% · 4Q avg 98.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.5%
5.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
3.3%
0.9 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 6.6% · Q3 1.6% · Q4 0.0% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 73.0% |
26.1%
46.9 pts worse
|
11.4%
61.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 54.2% · Q2 68.5% · Q3 80.4% · Q4 90.6% · 4Q avg 73.0% |
| Percentage of long-stay residents who lose too much weight | 10.3% |
6.2%
4.1 pts worse
|
5.4%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 6.0% · Q3 14.8% · Q4 12.5% · 4Q avg 10.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.8% |
25.4%
8.4 pts worse
|
19.6%
14.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 34.0% · Q3 35.2% · Q4 32.7% · 4Q avg 33.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.8% |
11.5%
1.7 pts better
|
16.7%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 10.3% · Q3 7.8% · Q4 7.1% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.7% |
7.7%
1 pts better
|
16.3%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.9% |
6.2%
2.7 pts worse
|
14.9%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 6.4% · Q3 4.0% · Q4 8.7% · 4Q avg 8.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.2%
0.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
0.5%
0.3 pts worse
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 1.6% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.0% |
21.7%
0.3 pts worse
|
19.8%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.1% · Q2 28.1% · Q3 9.6% · Q4 29.1% · 4Q avg 22.0% |
| Percentage of long-stay residents with pressure ulcers | 8.5% |
3.7%
4.8 pts worse
|
5.1%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 11.2% · Q3 5.5% · Q4 9.0% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
78.1%
19.2 pts better
|
81.7%
15.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.0% · Q4 92.5% · 4Q avg 97.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.6% |
12.5%
6.9 pts better
|
12.0%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.6% · Observed 5.6% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
75.6%
24.4 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.7% |
25.1%
0.6 pts worse
|
23.9%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.7% · Observed 22.2% · Expected 20.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-15 · Fire 2022-12-15
2 health deficiencies
Top issue: Environmental (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-09-26 · Fire 2019-09-26
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-05-23
E · Potential for more than minimal harm
2025-05-08
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-05-23
E · Potential for more than minimal harm
2025-05-08
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-05-23
E · Potential for more than minimal harm
2025-05-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-23
F · Potential for more than minimal harm
2022-12-15
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-01-11
F · Potential for more than minimal harm
2022-12-15
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-01-11
F · Potential for more than minimal harm
2022-12-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-11
F · Potential for more than minimal harm
2022-12-15
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-01-11
F · Potential for more than minimal harm
2022-12-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-11
E · Potential for more than minimal harm
2022-12-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-11
F · Potential for more than minimal harm
2019-09-26
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2019-11-01
F · Potential for more than minimal harm
2019-09-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-11-01
F · Potential for more than minimal harm
2019-09-26
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2019-11-01
F · Potential for more than minimal harm
2019-09-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-11-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-08
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-05-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-05-08
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-05-23
E · Potential for more than minimal harm
2023-11-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-05-26
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-06-09
E · Potential for more than minimal harm
2022-12-15
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-01-11
B · Minimal harm
2022-12-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-01-11
D · Potential for more than minimal harm
2019-09-26
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-11-01
D · Potential for more than minimal harm
2019-09-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-11-01
D · Potential for more than minimal harm
2019-09-26
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-11-01
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
Laurels Of Hillsboro
Hillsboro, OH
1-star overall rating with 1-star inspections with $119,308 in total fines with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Crestwood Ridge Skilled Nursing And Rehab
Hillsboro, OH
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Edgewood Manor Of Greenfield
Greenfield, OH
2-star overall rating with 2-star inspections with 13 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
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