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
Staffing
Hours and turnover
RN hours / resident day
0.54
Registered nurse staffing
LPN hours / resident day
1.11
Licensed practical nurse staffing
Aide hours / resident day
1.98
Nurse aide staffing
Weekend hours
3.16
Weekend nurse staffing
RN turnover
70%
Annual RN turnover
Total nurse turnover
58%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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