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

Staffing

Hours and turnover

RN hours / resident day

0.06

Registered nurse staffing

LPN hours / resident day

1.10

Licensed practical nurse staffing

Aide hours / resident day

2.91

Nurse aide staffing

Weekend hours

3.69

Weekend nurse staffing

RN turnover

Annual RN turnover

Total nurse turnover

27%

Annual nurse turnover

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
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
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
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
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
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
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
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	9.6%	18.4% 8.8 pts better	16.3% 6.7 pts better	Long Stay · 2024Q4-2025Q3
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
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
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
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
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
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

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