19 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Hillsboro, KS
1-star overall rating with 1-star inspections with $72,818 in total fines with 19 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
200 Willow Rd, Hillsboro, KS
(620) 947-2301
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
50
Certified beds
Average residents
34
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
RN hours / resident day
0.49
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
3.77
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.94
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.17
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.39
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.60
CMS adjusted RN staffing hours
Adjusted total hours
6.09
CMS adjusted total nurse staffing hours
Case-mix index
1.11
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
54%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
7,030
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.98
Composite VBP score used to determine payment impact.
Payment multiplier
0.9863
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
0
Baseline 7.02% · Performance 8.57% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.52
Baseline 67.74% · Performance 59.09% · Measure score 1.52 · Achievement 1.12 · Improvement 1.52
Adjusted total nurse staffing
7.78
Baseline 5.60 hours · Performance 5.29 hours · Measure score 7.78 · Achievement 7.78 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.38% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 51 · Observed rate 13.73% · Lower 95% interval 6.85% |
| Discharge to community | 44.59% |
50.57%
6 pts worse
|
No Different than the National Rate · Eligible stays 44 · Observed rate 36.36% · Lower 95% interval 32.02% |
| Medicare spending per beneficiary | 1.3 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 31 · Denominator 31 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 31 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 31 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.57% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 14.29% · Lower 95% interval 4.8% |
| Staff COVID-19 vaccination coverage | 4% |
8.2%
4.2 pts worse
|
Numerator 3 · Denominator 75 |
| Staff flu vaccination coverage | 23.86% |
42%
18.1 pts worse
|
Numerator 21 · Denominator 88 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.8
0.4 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 0.9 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.4 |
2.2
1.2 pts worse
|
1.8
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 2.4 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.6% |
91.8%
3.8 pts better
|
93.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.1% · Q2 97.2% · Q3 94.3% · Q4 96.9% · 4Q avg 95.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.1% |
95.5%
3.4 pts worse
|
95.5%
3.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
4.4%
0.7 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 8.6% · Q4 12.5% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.1% |
5.6%
2.5 pts better
|
11.4%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 2.8% · Q3 3.0% · Q4 3.6% · 4Q avg 3.1% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
5.0%
About the same
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.7% · Q3 6.5% · Q4 7.1% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.4% |
23.2%
3.8 pts better
|
19.6%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 18.8% · Q3 18.8% · Q4 16.7% · 4Q avg 19.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.4% |
19.8%
1.6 pts worse
|
16.7%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 18.5% · Q3 25.9% · Q4 20.0% · 4Q avg 21.4% · 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 | 28.5% |
18.4%
10.1 pts worse
|
16.3%
12.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.8% |
18.8%
9 pts worse
|
14.9%
12.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 27.6% · Q3 29.0% · Q4 32.1% · 4Q avg 27.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.8%
0.9 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.8% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
3.1%
2.3 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.3% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.3% |
23.2%
1.1 pts worse
|
19.8%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.5% · Q2 23.1% · Q3 22.6% · Q4 13.3% · 4Q avg 24.3% |
| Percentage of long-stay residents with pressure ulcers | 1.7% |
4.6%
2.9 pts better
|
5.1%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 49.1% |
75.6%
26.5 pts worse
|
81.7%
32.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 49.1% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Top issue: Resident Assessment and Care Planning (5 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire Safety
Use approved construction type or materials.
Corrected 2024-11-25
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-25
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 2024-11-25
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 2024-11-25
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-25
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-24
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-25
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-25
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-20
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-11-25
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-25
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-31
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-31
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-03-31
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-31
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-31
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-31
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-31
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 2023-03-31
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-31
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-31
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-03-31
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2021-09-27
Fire Safety
List the names and contact information of those in the facility.
Corrected 2021-09-27
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 2021-09-27
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-09-27
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2021-09-27
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-09-27
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-09-27
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-09-27
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-09-27
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-09-27
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-09-27
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2021-09-27
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-09-27
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-09-27
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-09-27
Inspection history
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-12
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-08
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-11-08
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-08
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-08
Health
Implement a program that monitors antibiotic use.
Corrected 2024-10-08
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-11-08
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-11-08
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-11-08
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-11-08
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-11-08
Health
Assess the resident when there is a significant change in condition
Corrected 2024-11-08
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-08
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-11-08
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-08
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 2024-11-08
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-08
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-08
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-11-08
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-09
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-05-16
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2023-05-16
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-06-09
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-01-31
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-01-31
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-01-31
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 2023-01-31
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-01-31
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-01-31
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 2023-01-31
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2021-08-20
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2021-08-20
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2021-08-20
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 2021-08-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-08-20
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-08-20
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-08-20
Penalties and ownership
Fine · fine $43,544
Fine
Payment Denial · denial start 2024-10-31 · 8 days
8 day denial
Fine · fine $13,397
Fine
Fine · fine $15,877
Fine
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Nearby options
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Marion, KS
3-star overall rating with 4-star inspections with 7 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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