Cycle 1
Health 2023-10-05 · Fire 2023-10-05
9 health deficiencies
Top issue: Resident Rights (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Hillsboro, OH
Laurels Of Hillsboro
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
175 Chillicothe Avenue, Hillsboro, OH
(937) 393-1925
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
74
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ciena Healthcare/Laurel Health Care
Operator or chain grouping
Approved since
1995-03-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
84 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
0.18
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.43
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.46
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
2.07
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
0.61
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
1.91
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.13
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.18
CMS adjusted RN staffing hours
Adjusted total hours
2.07
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
6,153
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.83
Composite VBP score used to determine payment impact.
Payment multiplier
0.9880
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.05
Baseline 20.96% · Performance 19.09% · Measure score 5.05 · Achievement 5.05 · Improvement 4.26
Healthcare-associated infections
0
Baseline 7.01% · Performance 7.71% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.08
Baseline 44.00% · Performance 38.82% · Measure score 6.08 · Achievement 6.08 · Improvement 2.20
Adjusted total nurse staffing
2.40
Baseline 3.12 hours · Performance 3.76 hours · Measure score 2.40 · Achievement 2.40 · Improvement 1.92
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.09% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 117 · Observed rate 15.38% · Lower 95% interval 8.31% |
| Discharge to community | 51.1% |
50.57%
0.5 pts better
|
No Different than the National Rate · Eligible stays 82 · Observed rate 45.12% · Lower 95% interval 39.92% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 32.08% |
95.27%
63.2 pts worse
|
Numerator 17 · Denominator 53 |
| Falls with major injury | 1.89% |
0.77%
1.1 pts worse
|
Numerator 1 · Denominator 53 |
| Discharge self-care score | 53.85% |
53.69%
0.2 pts better
|
Numerator 21 · Denominator 39 |
| Discharge mobility score | 48.72% |
50.94%
2.2 pts worse
|
Numerator 19 · Denominator 39 |
| Pressure ulcers or injuries, new or worsened | 3.77% |
2.29%
1.5 pts worse
|
Numerator 2 · Denominator 53 · Adjusted rate 3.07% |
| Healthcare-associated infections requiring hospitalization | 7.71% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 56 · Observed rate 8.93% · Lower 95% interval 4.64% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 144 |
| Staff flu vaccination coverage | 4.55% |
42%
37.5 pts worse
|
Numerator 6 · Denominator 132 |
| Discharge function score | 43.59% |
56.45%
12.9 pts worse
|
Numerator 17 · Denominator 39 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 4.55% |
25.2%
20.6 pts worse
|
Numerator 1 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.8
0.1 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 2.2 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
1.8
0.9 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 3.1 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
92.4%
6.5 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.8% · Q3 100.0% · Q4 100.0% · 4Q avg 98.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.6% |
94.5%
3.1 pts better
|
95.5%
2.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.4% |
3.3%
2.1 pts worse
|
3.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 5.6% · Q3 6.0% · Q4 8.8% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.6% |
26.1%
17.5 pts better
|
11.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 8.1% · Q3 17.2% · Q4 5.2% · 4Q avg 8.6% |
| Percentage of long-stay residents who lose too much weight | 13.7% |
6.2%
7.5 pts worse
|
5.4%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 14.9% · Q3 13.8% · Q4 13.6% · 4Q avg 13.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.1% |
25.4%
0.7 pts worse
|
19.6%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 22.1% · Q3 23.7% · Q4 38.3% · 4Q avg 26.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.0% |
11.5%
9.5 pts worse
|
16.7%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 22.6% · Q3 22.4% · Q4 10.4% · 4Q avg 21.0% · 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 | 10.2% |
7.7%
2.5 pts worse
|
16.3%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 10.4% · Q3 3.9% · Q4 17.8% · 4Q avg 10.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.8% |
6.2%
3.6 pts worse
|
14.9%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 13.6% · Q3 3.5% · Q4 10.3% · 4Q avg 9.8% · 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 | 1.1% |
0.5%
0.6 pts worse
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.9% |
21.7%
0.8 pts better
|
19.8%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 25.2% · Q3 17.4% · Q4 25.2% · 4Q avg 20.9% |
| Percentage of long-stay residents with pressure ulcers | 8.0% |
3.7%
4.3 pts worse
|
5.1%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 7.1% · Q3 6.8% · Q4 10.6% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.6% |
78.1%
1.5 pts worse
|
81.7%
5.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 80.0% · Q2 80.4% · Q3 80.4% · Q4 64.0% · 4Q avg 76.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.5% |
12.5%
5 pts better
|
12.0%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.5% · Observed 8.0% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.6% |
1.2%
1.4 pts worse
|
1.6%
1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.3% · Q3 1.6% · Q4 3.8% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.7% |
75.6%
8.1 pts better
|
79.7%
4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 10.8% |
25.1%
14.3 pts better
|
23.9%
13.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 12.0% · Expected 26.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-09 · Fire 2022-06-09
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2019-08-15 · Fire 2019-08-15
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-10-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-08
F · Potential for more than minimal harm
2023-10-05
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2023-12-08
F · Potential for more than minimal harm
2023-10-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-08
F · Potential for more than minimal harm
2023-10-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-08
F · Potential for more than minimal harm
2023-10-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-08
F · Potential for more than minimal harm
2023-10-05
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-12-08
F · Potential for more than minimal harm
2023-10-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-08
E · Potential for more than minimal harm
2023-10-05
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-12-08
F · Potential for more than minimal harm
2022-06-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-07-29
F · Potential for more than minimal harm
2022-06-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-29
F · Potential for more than minimal harm
2022-06-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-07-29
F · Potential for more than minimal harm
2022-06-09
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 2022-07-29
F · Potential for more than minimal harm
2022-06-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-29
E · Potential for more than minimal harm
2022-06-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-07-29
F · Potential for more than minimal harm
2019-08-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-09-26
F · Potential for more than minimal harm
2019-08-15
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-09-26
Inspection history
Recent health citations
J · Immediate jeopardy
2025-12-29
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-12-30
D · Potential for more than minimal harm
2025-12-29
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-12-30
F · Potential for more than minimal harm
2025-08-13
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-09-08
G · Actual harm
2023-10-31
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 2023-10-13
L · Immediate jeopardy
2023-10-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-10-05
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-10-05
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 2023-12-08
D · Potential for more than minimal harm
2023-10-05
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-10-05
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 2023-12-08
D · Potential for more than minimal harm
2023-10-05
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2023-12-08
E · Potential for more than minimal harm
2022-06-09
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2022-07-29
D · Potential for more than minimal harm
2022-06-09
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 2022-07-29
D · Potential for more than minimal harm
2022-06-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-07-29
D · Potential for more than minimal harm
2022-06-09
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 2022-07-29
D · Potential for more than minimal harm
2019-08-15
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-09-26
D · Potential for more than minimal harm
2019-08-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2019-09-26
D · Potential for more than minimal harm
2019-08-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-09-26
D · Potential for more than minimal harm
2019-08-15
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2019-09-26
D · Potential for more than minimal harm
2019-08-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-09-26
Penalties and ownership
What sits behind the stars
$119,308
2023-10-05
Fine
Fine · fine $119,308
Fine
$0
2023-10-05
Payment Denial
Payment Denial · denial start 2023-10-31 · 38 days
38 day denial
Ownership
Nearby options
Other facilities in reach
#1
Hillsboro Post Acute
Hillsboro, OH
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 4 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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