01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-01-07 | 5 | 2026-01-07 | 2 |
| Cycle 2 | 2024-02-20 | 5 | 2024-02-20 | 10 |
| Cycle 3 | 2022-08-02 | 8 | 2022-08-02 | 18 |
CMS CCN 1754722026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Hillside Village Of De Soto Rehabilitation And Nur
33600 West 85Th Street · De Soto, KS 66018 · Johnson County
Certified beds49CMS provider file
Recent citation rows48current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
48 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 12 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-01-07 · HEALTHF0628Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Correction field: Deficient, Provider has date of correction · 2026-02-202026-01-07 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2026-02-202026-01-07 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2026-02-202026-01-07 · HEALTHF0868Severity E · pattern; potential for more than minimal harm
Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Correction field: Deficient, Provider has date of correction · 2026-02-202026-01-07 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-02-202026-01-07 · FIREK0291Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2026-02-272026-01-07 · FIREK0511Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2026-02-272024-02-20 · FIREE0009Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Include a process for Emergency Preparedness collaboration.
Correction field: Deficient, Provider has date of correction · 2024-04-262024-02-20 · HEALTHF0730Severity F · widespread; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
Correction field: Deficient, Provider has date of correction · 2024-03-282024-02-20 · HEALTHF0756Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Correction field: Deficient, Provider has date of correction · 2024-03-282024-02-20 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-03-282024-02-20 · HEALTHF0880Severity F · widespread; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-03-282024-02-20 · HEALTHF0947Severity F · widespread; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Correction field: Deficient, Provider has date of correction · 2024-03-282024-02-20 · FIREK0291Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2024-04-262024-02-20 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2024-04-262024-02-20 · FIREK0353Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2024-04-262024-02-20 · FIREK0363Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2024-04-262024-02-20 · FIREK0511Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2024-04-262024-02-20 · FIREK0712Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2024-04-262024-02-20 · FIREK0741Severity D · isolated; potential for more than minimal harm
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Correction field: Deficient, Provider has date of correction · 2024-04-262024-02-20 · FIREK0914Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Correction field: Deficient, Provider has date of correction · 2024-04-262024-02-20 · FIREK0920Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Correction field: Deficient, Provider has date of correction · 2024-04-262022-08-02 · FIREE0004Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Develop and maintain an Emergency Preparedness Program (EP).
Correction field: Deficient, Provider has date of correction · 2022-10-102022-08-02 · FIREE0009Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Include a process for Emergency Preparedness collaboration.
Correction field: Deficient, Provider has date of correction · 2022-10-1003 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- GATEWAY HEALTHCARE LLCOrganization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 02/26/2024
- DEAN, ETHANIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 08/13/2024
- LEE, JESSICAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 05/01/2024
- BURNAM, SOONIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/26/2024
- DEAN, ETHANIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/13/2024
- JORGENSEN, DAVIDIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/26/2024
- KEETCH, CHADIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/26/2024
- LEE, JESSICAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/01/2024
- PORT, BARRYIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 04/09/2026
- ABBOT HEALTH HOLDINGS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 05/01/2024
- ENSIGN SERVICES INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 05/01/2024
- STANDARD BEARER HEALTHCARE OP LPOrganization · ADP OF THE SNFNOT APPLICABLE · since 05/01/2024
- THE ENSIGN GROUP INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 05/01/2024
- DEAN, ETHANIndividual · ADP OF THE SNFNOT APPLICABLE · since 04/09/2026
- LEE, JESSICAIndividual · ADP OF THE SNFNOT APPLICABLE · since 04/09/2026
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.79per resident day
RN hours0.60per resident day
Weekend nurse hours3.45per resident day
Staff turnover45.2%CMS reported field
06 / LOCAL RECORDS
Open the Kansas ledger →Other published facilities nearby
No second facility in the same city met the directory rule.