Cycle 1
Health 2026-01-07 · Fire 2026-01-07
5 health deficiencies
Top issue: Administration (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
De Soto, KS
Hillside Village Of De Soto Rehabilitation And Nur
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
33600 West 85th Street, De Soto, KS
(913) 583-1266
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
49
Certified beds
Average residents
42
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2003-11-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 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
0.63
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.13
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.67
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.25
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.86
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.62
CMS adjusted RN staffing hours
Adjusted total hours
3.62
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
64%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,892
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.85
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
Performance 23.36% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.11
Performance 6.61% · Measure score 4.11 · Achievement 4.11 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
0
Performance 64.91% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.83
Baseline 4.28 hours · Performance 3.60 hours · Measure score 1.83 · Achievement 1.83 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.66% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 37 · Observed rate 16.22% · Lower 95% interval 7.75% |
| Discharge to community | 48.26% |
50.57%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 25 · Observed rate 40% · Lower 95% interval 34.26% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 91.84% |
95.27%
3.4 pts worse
|
Numerator 45 · Denominator 49 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 49 |
| Discharge self-care score | 42.42% |
53.69%
11.3 pts worse
|
Numerator 14 · Denominator 33 |
| Discharge mobility score | 45.45% |
50.94%
5.5 pts worse
|
Numerator 15 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 4.08% |
2.29%
1.8 pts worse
|
Numerator 2 · Denominator 49 · Adjusted rate 4.15% |
| Healthcare-associated infections requiring hospitalization | 6.61% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 29 · Observed rate 3.45% · Lower 95% interval 3.53% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 83 |
| Staff flu vaccination coverage | 24.43% |
42%
17.6 pts worse
|
Numerator 32 · Denominator 131 |
| Discharge function score | 54.55% |
56.45%
1.9 pts worse
|
Numerator 18 · Denominator 33 |
| Transfer of health information to provider | 80% |
95.95%
16 pts worse
|
Numerator 16 · Denominator 20 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 59.46% |
25.2%
34.3 pts better
|
Numerator 22 · Denominator 37 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
1.8
1.1 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 3.1 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
2.2
1.3 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.0% |
91.8%
3.2 pts better
|
93.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 89.3% · Q4 90.0% · 4Q avg 95.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.9% |
95.5%
3.6 pts worse
|
95.5%
3.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.8% |
4.4%
1.4 pts worse
|
3.3%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 3.3% · Q3 3.6% · Q4 6.7% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.6% |
5.6%
2 pts worse
|
11.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 7.4% · Q3 0.0% · Q4 20.0% · 4Q avg 7.6% |
| Percentage of long-stay residents who lose too much weight | 14.0% |
5.0%
9 pts worse
|
5.4%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.5% · Q3 33.3% · Q4 20.0% · 4Q avg 14.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.0% |
23.2%
10.8 pts worse
|
19.6%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 30.4% · Q3 39.1% · Q4 39.1% · 4Q avg 34.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.3% |
19.8%
6.5 pts better
|
16.7%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
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 | 29.2% |
18.4%
10.8 pts worse
|
16.3%
12.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.2% |
18.8%
3.6 pts better
|
14.9%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 4.5% · Q3 30.4% · Q4 13.0% · 4Q avg 15.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.8%
1.8 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 | 2.7% |
3.1%
0.4 pts better
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.9% · Q3 0.0% · Q4 3.7% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.2% |
23.2%
10 pts worse
|
19.8%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.2% · Q2 26.9% · Q3 24.9% · Q4 38.4% · 4Q avg 33.2% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
4.6%
2.6 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 4.9% · Q3 0.0% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.3% |
75.6%
3.7 pts better
|
81.7%
2.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 90.2% · Q2 79.6% · Q3 75.9% · Q4 74.1% · 4Q avg 79.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.5% |
11.7%
1.2 pts better
|
12.0%
1.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.5% · Observed 10.2% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
2.2%
1.2 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.7% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.0% |
73.5%
12.5 pts better
|
79.7%
6.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.5% |
23.0%
11.5 pts worse
|
23.9%
10.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.5% · Observed 30.6% · Expected 21.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-20 · Fire 2024-02-20
5 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-08-02 · Fire 2022-08-02
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
18 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-07
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2026-02-27
D · Potential for more than minimal harm
2026-01-07
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2026-02-27
F · Potential for more than minimal harm
2024-02-20
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-04-26
F · Potential for more than minimal harm
2024-02-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-26
F · Potential for more than minimal harm
2024-02-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-26
F · Potential for more than minimal harm
2024-02-20
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 2024-04-26
F · Potential for more than minimal harm
2024-02-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-26
E · Potential for more than minimal harm
2024-02-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-04-26
E · Potential for more than minimal harm
2024-02-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-02-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-02-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-02-20
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-04-26
F · Potential for more than minimal harm
2022-08-02
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-08-02
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-08-02
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-08-02
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-08-02
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-08-02
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-08-02
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 2022-10-10
F · Potential for more than minimal harm
2022-08-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-08-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-08-02
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-08-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-08-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-08-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-08-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-08-02
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-08-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-10-10
D · Potential for more than minimal harm
2022-08-02
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-10-10
D · Potential for more than minimal harm
2022-08-02
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-10-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-07
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.
Not marked corrected
E · Potential for more than minimal harm
2026-01-07
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Not marked corrected
D · Potential for more than minimal harm
2026-01-07
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Not marked corrected
D · Potential for more than minimal harm
2026-01-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Not marked corrected
D · Potential for more than minimal harm
2026-01-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Not marked corrected
F · Potential for more than minimal harm
2024-02-20
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-03-28
F · Potential for more than minimal harm
2024-02-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-28
F · Potential for more than minimal harm
2024-02-20
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-03-28
D · Potential for more than minimal harm
2024-02-20
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-03-28
D · Potential for more than minimal harm
2024-02-20
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 2024-03-28
F · Potential for more than minimal harm
2022-08-02
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 2022-09-06
E · Potential for more than minimal harm
2022-08-02
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2022-09-06
E · Potential for more than minimal harm
2022-08-02
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-09-06
E · Potential for more than minimal harm
2022-08-02
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 2022-09-06
E · Potential for more than minimal harm
2022-08-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-06
D · Potential for more than minimal harm
2022-08-02
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-09-06
D · Potential for more than minimal harm
2022-08-02
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-09-06
D · Potential for more than minimal harm
2022-08-02
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 2022-09-06
Penalties and ownership
What sits behind the stars
Ownership
Gateway Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Fitch, Craig
Corporate Officer · Individual
Jorgensen, David
Corporate Director · Individual
Lewis, Corwin
Operational/Managerial Control · Individual
Lewis, Corwin
Corporate Officer · Individual
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