Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

HILLSIDE VILLAGE OF DE SOTO REHABILITATION AND NUR

DE SOTO, KS · 49 certified beds · Last Life Safety survey January 7, 2026

CMS Certification Number 175472 · first certified November 2003

Ownership

Operated by THE ENSIGN GROUP · For profit - Corporation

  • Ownership changed May 1, 2024 (change of ownership)to HILLSIDE VILLAGE OF DE SOTO REHABILITATION AND NURSING CENTER from HILLSIDE VILLAGE LLC
30
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
8
Tags cited more than once
Across separate surveys
15
Inspection & testing records
Of the citations on file

Position within KS

30 citations — more than 60% of the 296 certified nursing homes in KS. Compared within KS rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 2 citations; the earlier surveys in the window averaged 14. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens August 2027 — about 11 months from now. This facility’s last Life Safety survey was January 2026. Facilities in KS are typically surveyed 20–22 months after the last one (median 21), measured over 298 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

6 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

5 of the 30 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 30 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in KS, and nationally. Surveyors differ markedly between states, so the KS figure is the meaningful one.

This facility30KS median27National median11
Citations on file over three years, compared
MeasureCitations
This facility30
Median facility in KS27
Median facility nationally11

Survey history

Citations at each Life Safety survey
182022-08102024-0222026-01
Citations at each Life Safety survey
Survey dateCitations
August 2, 202218
February 20, 202410
January 7, 20262

Most-cited tags

Most-cited tags at this facility
K-02913K-05112K-03452K-03532K-09202E-00092K-03632K-07122
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0291Install emergency lighting that can last at least 1 1/2 hours.32026-01-07
K-0511Have properly installed electrical wiring and gas equipment.22026-01-07
K-0345Have approved installation, maintenance and testing program for fire alarm systems.22024-02-20
K-0353Inspect, test, and maintain automatic sprinkler systems.22024-02-20
K-0920Ensure proper usage of power strips and extension cords.22024-02-20
E-0009Include a process for Emergency Preparedness collaboration.22024-02-20
K-0363Install corridor and hallway doors that block smoke.22024-02-20
K-0712Have simulated fire drills held at unexpected times.22024-02-20

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 10
  • Emergency Preparedness Deficiencies 5
  • Miscellaneous Deficiencies 4
  • Egress Deficiencies 4
  • Other 7
Citations by CMS category
CategoryCitations
Smoke Deficiencies10
Emergency Preparedness Deficiencies5
Miscellaneous Deficiencies4
Egress Deficiencies4
Gas, Vacuum, and Electrical Systems Deficiencies3
Services Deficiencies2
Construction Deficiencies2

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

January 7, 2026 — 2 citations

Citations issued on January 7, 2026
TagWhat the surveyor checksStatus
K-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (February 27, 2026)
K-0511Have properly installed electrical wiring and gas equipment.Deficient, Provider has date of correction (February 27, 2026)

February 20, 2024 — 10 citations

Citations issued on February 20, 2024
TagWhat the surveyor checksStatus
E-0009Include a process for Emergency Preparedness collaboration.Deficient, Provider has date of correction (April 26, 2024)
K-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (April 26, 2024)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (April 26, 2024)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (April 26, 2024)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (April 26, 2024)
K-0511Have properly installed electrical wiring and gas equipment.Deficient, Provider has date of correction (April 26, 2024)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (April 26, 2024)
K-0741Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.Deficient, Provider has date of correction (April 26, 2024)
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.Deficient, Provider has date of correction (April 26, 2024)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (April 26, 2024)

August 2, 2022 — 18 citations

Citations issued on August 2, 2022
TagWhat the surveyor checksStatus
E-0004Develop and maintain an Emergency Preparedness Program (EP).Deficient, Provider has date of correction (October 10, 2022)
E-0009Include a process for Emergency Preparedness collaboration.Deficient, Provider has date of correction (October 10, 2022)
E-0024Establish policies and procedures for volunteers.Deficient, Provider has date of correction (October 10, 2022)
E-0034Provide a means of sharing information on occupancy/needs.Deficient, Provider has date of correction (October 10, 2022)
K-0132Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.Deficient, Provider has date of correction (October 10, 2022)
K-0161Use approved construction type or materials.Deficient, Provider has date of correction (October 10, 2022)
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (October 10, 2022)
K-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (October 10, 2022)
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (October 10, 2022)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (October 10, 2022)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (October 10, 2022)
K-0346Follow proper procedures when the fire alarm was out of service for more than 4 hours.Deficient, Provider has date of correction (October 10, 2022)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (October 10, 2022)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (October 10, 2022)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (October 10, 2022)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (October 10, 2022)
K-0753Have restrictions on the use of highly flammable decorations.Deficient, Provider has date of correction (October 10, 2022)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (October 10, 2022)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.