Phillipsburg, KS

Phillips County Retirement Center

1-star overall rating with 2-star inspections with abuse icon flag with 12 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle

1300 State Street, Phillipsburg, KS

(785) 543-2131

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2017-04-08

CMS approved date

Coverage

Medicaid

Participation flags

Changed ownership

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

0.06

Registered nurse staffing · state 0.72 · national 0.68

LPN hours / resident day

1.10

Licensed practical nurse staffing · state 0.67 · national 0.87

Aide hours / resident day

2.91

Nurse aide staffing · state 2.69 · national 2.35

Total nurse hours

4.06

All reported nurse hours · state 4.07 · national 3.89

Licensed hours

1.15

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

3.69

Weekend nurse staffing · state 3.58 · national 3.43

Weekend RN hours

0.06

Weekend registered nurse coverage · state 0.50 · national 0.47

Physical therapist

0.00

Reported PT staffing · state 0.04 · national 0.07

Adjusted RN hours

0.07

CMS adjusted RN staffing hours

Adjusted total hours

5.11

CMS adjusted total nurse staffing hours

Case-mix index

1.09

Higher values indicate more complex resident acuity

RN turnover

Annual RN turnover

Total nurse turnover

27%

Annual nurse turnover · state 50% · national 46%

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Medicare spending per beneficiary	Not Available	1.02	This provider is not required to submit SNF QRP data.
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · This provider is not required to submit SNF QRP data.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Staff COVID-19 vaccination coverage	Not Available	8.2%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	96.6%	91.8% 4.8 pts better	93.4% 3.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 96.6% · Q2 100.0% · Q3 100.0% · Q4 90.0% · 4Q avg 96.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	95.5% 4.5 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	8.5%	4.4% 4.1 pts worse	3.3% 5.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 10.3% · Q3 6.7% · Q4 10.0% · 4Q avg 8.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.0%	5.6% 4.6 pts better	11.4% 10.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0%
Percentage of long-stay residents who lose too much weight	7.1%	5.0% 2.1 pts worse	5.4% 1.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 3.7% · Q3 10.0% · Q4 3.4% · 4Q avg 7.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	46.0%	23.2% 22.8 pts worse	19.6% 26.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 37.0% · Q2 40.7% · Q3 53.3% · Q4 51.7% · 4Q avg 46.0%
Percentage of long-stay residents who received an antipsychotic medication	7.3%	19.8% 12.5 pts better	16.7% 9.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 9.1% · Q3 3.7% · Q4 7.4% · 4Q avg 7.3% · 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	9.6%	18.4% 8.8 pts better	16.3% 6.7 pts better	Long Stay · 2024Q4-2025Q3 · Q4 8.1% · 4Q avg 9.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	9.0%	18.8% 9.8 pts better	14.9% 5.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 8.0% · Q3 7.7% · Q4 11.5% · 4Q avg 9.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	3.2%	1.8% 1.4 pts worse	1.0% 2.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 8.5% · Q3 0.0% · Q4 0.0% · 4Q avg 3.2% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	6.8%	3.1% 3.7 pts worse	1.7% 5.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.4% · Q3 10.0% · Q4 10.0% · 4Q avg 6.8% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	15.3%	23.2% 7.9 pts better	19.8% 4.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 32.4% · Q3 9.2% · Q4 5.9% · 4Q avg 15.3%
Percentage of long-stay residents with pressure ulcers	7.5%	4.6% 2.9 pts worse	5.1% 2.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 12.8% · Q3 4.1% · Q4 3.4% · 4Q avg 7.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	60.9%	75.6% 14.7 pts worse	81.7% 20.8 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 60.9%

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-05-16 · Fire 2024-05-16

12 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

7 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2022-06-16 · Fire 2022-06-16

13 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

5 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Cycle 3 Health 2020-10-14 · Fire 2020-10-14

5 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

7 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-05-16

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-08-14

F · Potential for more than minimal harm 2024-05-16

K901 · Electrical Deficiencies

Fire Safety

Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.

Corrected 2024-07-18

E · Potential for more than minimal harm 2024-05-16

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 2024-08-14

E · Potential for more than minimal harm 2024-05-16

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-07-03

E · Potential for more than minimal harm 2024-05-16

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-07-03

E · Potential for more than minimal harm 2024-05-16

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-08-14

D · Potential for more than minimal harm 2024-05-16

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-08-14

F · Potential for more than minimal harm 2022-06-16

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 2022-08-25

F · Potential for more than minimal harm 2022-06-16

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2022-08-25

F · Potential for more than minimal harm 2022-06-16

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2022-08-25

E · Potential for more than minimal harm 2022-06-16

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2022-08-25

E · Potential for more than minimal harm 2022-06-16

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 2022-08-25

F · Potential for more than minimal harm 2020-10-14

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2020-03-21

E · Potential for more than minimal harm 2020-10-14

K131 · Construction Deficiencies

Fire Safety

Meet requirements for sections of health care facilities separated by fire resistive construction.

Corrected 2020-03-21

E · Potential for more than minimal harm 2020-10-14

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2020-03-21

E · Potential for more than minimal harm 2020-10-14

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 2020-03-21

E · Potential for more than minimal harm 2020-10-14

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2020-03-21

D · Potential for more than minimal harm 2020-10-14

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2020-03-21

D · Potential for more than minimal harm 2020-10-14

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2020-03-21

Inspection history

Recent health citations

J · Immediate jeopardy 2024-05-16

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-06-07

F · Potential for more than minimal harm 2024-05-16

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 2024-06-07

F · Potential for more than minimal harm 2024-05-16

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-06-07

E · Potential for more than minimal harm 2024-05-16

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 2024-06-07

D · Potential for more than minimal harm 2024-05-16

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 2024-06-07

D · Potential for more than minimal harm 2024-05-16

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-06-07

D · Potential for more than minimal harm 2024-05-16

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 2024-06-07

D · Potential for more than minimal harm 2024-05-16

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 2024-06-07

D · Potential for more than minimal harm 2024-05-16

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 2024-06-07

D · Potential for more than minimal harm 2024-05-16

F761 · Pharmacy Service Deficiencies

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 2024-06-07

D · Potential for more than minimal harm 2024-05-16

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected 2024-06-07

D · Potential for more than minimal harm 2024-05-16

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2024-06-07

F · Potential for more than minimal harm 2022-06-16

F576 · Resident Rights Deficiencies

Health

Ensure residents have reasonable access to and privacy in their use of communication methods.

Corrected 2022-07-08

E · Potential for more than minimal harm 2022-06-16

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 2022-07-08

E · Potential for more than minimal harm 2022-06-16

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 2022-07-08

E · Potential for more than minimal harm 2022-06-16

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 2022-07-08

D · Potential for more than minimal harm 2022-06-16

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2022-07-08

D · Potential for more than minimal harm 2022-06-16

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2022-07-08

D · Potential for more than minimal harm 2022-06-16

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 2022-07-08

D · Potential for more than minimal harm 2022-06-16

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2022-07-08

D · Potential for more than minimal harm 2022-06-16

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2022-07-08

D · Potential for more than minimal harm 2022-06-16

F700 · Quality of Life and Care Deficiencies

Health

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Corrected 2022-07-08

D · Potential for more than minimal harm 2022-06-16

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 2022-07-08

D · Potential for more than minimal harm 2022-06-16

F758 · Pharmacy Service Deficiencies

Health

Corrected 2022-07-08

D · Potential for more than minimal harm 2022-06-16

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2022-07-08

F · Potential for more than minimal harm 2020-10-14

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 2020-10-30

E · Potential for more than minimal harm 2020-10-14

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2020-10-30

D · Potential for more than minimal harm 2020-10-14

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2020-10-23

D · Potential for more than minimal harm 2020-10-14

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 2020-10-26

D · Potential for more than minimal harm 2020-10-14

F690 · Quality of Life and Care Deficiencies

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 2020-10-22

Penalties and ownership