6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Hesston, KS
5-star overall rating with 5-star inspections with 6 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
200 W Cedar, Hesston, KS
(620) 327-0400
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
105
Certified beds
Average residents
96
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
0.79
Registered nurse staffing
LPN hours / resident day
0.68
Licensed practical nurse staffing
Aide hours / resident day
3.51
Nurse aide staffing
Weekend hours
4.50
Weekend nurse staffing
RN turnover
61%
Annual RN turnover
Total nurse turnover
52%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.8
0.6 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.2
0.9 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.1% |
91.8%
1.7 pts worse
|
93.4%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.0% |
95.5%
1.5 pts worse
|
95.5%
1.5 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 10.7% |
4.4%
6.3 pts worse
|
3.3%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 2.9% |
5.6%
2.7 pts better
|
11.4%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 5.4% |
5.0%
0.4 pts worse
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.5% |
23.2%
7.7 pts better
|
19.6%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 15.6% |
19.8%
4.2 pts better
|
16.7%
1.1 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 | 25.1% |
18.4%
6.7 pts worse
|
16.3%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 37.5% |
18.8%
18.7 pts worse
|
14.9%
22.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.9% |
1.8%
1.1 pts worse
|
1.0%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.8% |
3.1%
0.3 pts better
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.7% |
23.2%
4.5 pts worse
|
19.8%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 0.3% |
4.6%
4.3 pts better
|
5.1%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 67.2% |
75.6%
8.4 pts worse
|
81.7%
14.5 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.8% |
11.7%
2.1 pts worse
|
12.0%
1.8 pts worse
|
Short Stay · 20240701-20250630 |
| 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 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 72.4% |
73.5%
1.1 pts worse
|
79.7%
7.3 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.5% |
23.0%
4.5 pts better
|
23.9%
5.4 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Pharmacy Service (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
No concentrated health issue counts in this cycle.
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
No concentrated health issue counts in this cycle.
16 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-12-12
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-12-12
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 2024-12-19
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-12-12
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-12
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-12
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-12
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-12
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-19
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 2023-03-16
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 2023-03-16
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-16
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-16
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-16
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-16
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-16
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-16
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-03-16
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2021-09-16
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2021-09-16
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-09-16
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2021-09-16
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-09-16
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2021-09-16
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-09-16
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2021-09-16
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-09-16
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-09-16
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-09-16
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-09-16
Fire Safety
Use approved construction type or materials.
Corrected 2021-09-16
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 2021-09-16
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-09-16
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2021-09-16
Inspection history
Health
Provide activities to meet all resident's needs.
Corrected 2024-12-02
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 2024-12-02
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 2024-12-02
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 2024-12-02
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 2024-12-02
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-12-02
Penalties and ownership
Operational/Managerial Control · Organization
Corporate Director · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
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