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
Staffing
RN hours / resident day
0.49
Registered nurse staffing
LPN hours / resident day
0.68
Licensed practical nurse staffing
Aide hours / resident day
3.77
Nurse aide staffing
Weekend hours
4.39
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
54%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
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