Hugoton, KS

Stevens County Hospital Ltcu DBA Pioneer Manor

1-star overall rating with 1-star inspections with 18 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

1711 S Main Street, Hugoton, KS

(620) 544-2023

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

77

Certified beds

Average residents

71

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1987-08-19

CMS approved date

Coverage

Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.64

Registered nurse staffing

LPN hours / resident day

0.45

Licensed practical nurse staffing

Aide hours / resident day

3.28

Nurse aide staffing

Weekend hours

3.86

Weekend nurse staffing

RN turnover

0%

Annual RN turnover

Total nurse turnover

0%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 2.5
1.8
0.7 pts worse
1.9
0.6 pts worse
Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days 3.9
2.2
1.7 pts worse
1.8
2.1 pts worse
Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 53.7%
91.8%
38.1 pts worse
93.4%
39.7 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 96.1%
95.5%
0.6 pts better
95.5%
0.6 pts better
Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury 6.6%
4.4%
2.2 pts worse
3.3%
3.3 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms 3.0%
5.6%
2.6 pts better
11.4%
8.4 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight 6.3%
5.0%
1.3 pts worse
5.4%
0.9 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication 6.3%
23.2%
16.9 pts better
19.6%
13.3 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication 4.3%
19.8%
15.5 pts better
16.7%
12.4 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 18.9%
18.4%
0.5 pts worse
16.3%
2.6 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased 17.9%
18.8%
0.9 pts better
14.9%
3 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder 1.0%
1.8%
0.8 pts better
1.0%
About the same
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection 4.9%
3.1%
1.8 pts worse
1.7%
3.2 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 23.5%
23.2%
0.3 pts worse
19.8%
3.7 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers 5.5%
4.6%
0.9 pts worse
5.1%
0.4 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 61.9%
75.6%
13.7 pts worse
81.7%
19.8 pts worse
Short Stay · 2024Q4-2025Q3

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-12-12 · Fire 2024-12-12

18 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

8 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)

Cycle 2 Health 2023-01-26 · Fire 2023-01-26

1 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2021-05-19 · Fire 2021-05-19

3 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-12-12

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-02-13

F · Potential for more than minimal harm 2024-12-12

K761 · Miscellaneous Deficiencies

Fire Safety

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

Corrected 2025-02-13

F · Potential for more than minimal harm 2024-12-12

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2025-02-13

F · Potential for more than minimal harm 2024-12-12

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-02-13

F · Potential for more than minimal harm 2024-12-12

K926 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.

Corrected 2025-02-13

E · Potential for more than minimal harm 2024-12-12

K133 · Construction Deficiencies

Fire Safety

Install a two-hour-resistant firewall separation.

Corrected 2025-02-13

E · Potential for more than minimal harm 2024-12-12

K372 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-02-13

D · Potential for more than minimal harm 2024-12-12

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 2025-02-13

F · Potential for more than minimal harm 2021-05-19

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2021-08-05

Inspection history

Recent health citations

G · Actual harm 2024-12-12

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2025-02-25

G · Actual harm 2024-12-12

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-02-25

G · Actual harm 2024-12-12

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2025-02-25

F · Potential for more than minimal harm 2024-12-12

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-02-25

F · Potential for more than minimal harm 2024-12-12

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2025-02-25

F · Potential for more than minimal harm 2024-12-12

F882 · Infection Control Deficiencies

Health

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Corrected 2025-02-25

F · Potential for more than minimal harm 2024-12-12

F947 · Nursing and Physician Services Deficiencies

Health

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected 2025-02-25

E · Potential for more than minimal harm 2024-12-12

F578 · Resident Rights Deficiencies

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 2025-02-25

E · Potential for more than minimal harm 2024-12-12

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-02-25

E · Potential for more than minimal harm 2024-12-12

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 2025-02-25

E · Potential for more than minimal harm 2024-12-12

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-02-25

E · Potential for more than minimal harm 2024-12-12

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2025-02-25

E · Potential for more than minimal harm 2024-12-12

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 2025-02-25

E · Potential for more than minimal harm 2024-12-12

F883 · Infection Control Deficiencies

Health

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

Corrected 2025-02-25

D · Potential for more than minimal harm 2024-12-12

F660 · Resident Assessment and Care Planning Deficiencies

Health

Plan the resident's discharge to meet the resident's goals and needs.

Corrected 2025-02-25

D · Potential for more than minimal harm 2024-12-12

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 2025-02-25

D · Potential for more than minimal harm 2024-12-12

F742 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Corrected 2025-02-25

D · Potential for more than minimal harm 2024-12-12

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 2025-02-25

D · Potential for more than minimal harm 2023-01-26

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 2023-02-06

E · Potential for more than minimal harm 2021-05-19

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 2021-06-02

D · Potential for more than minimal harm 2021-05-19

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 2021-06-02

D · Potential for more than minimal harm 2021-05-19

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 2021-05-19

Penalties and ownership

What sits behind the stars

Ownership

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