8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Shawnee, KS
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
10315 Johnson Drive, Shawnee, KS
(913) 631-8200
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
78
Certified beds
Average residents
46
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Weekend hours
0.00
Weekend nurse staffing
RN turnover
20%
Annual RN turnover
Total nurse turnover
34%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.3 |
1.8
1.5 pts worse
|
1.9
1.4 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
2.2
1.9 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
91.8%
7.5 pts better
|
93.4%
5.9 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 | 2.8% |
4.4%
1.6 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 4.5% |
5.6%
1.1 pts better
|
11.4%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 3.4% |
5.0%
1.6 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.7% |
23.2%
11.5 pts better
|
19.6%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
19.8%
19.8 pts better
|
16.7%
16.7 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 | 19.5% |
18.4%
1.1 pts worse
|
16.3%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.2% |
18.8%
5.6 pts better
|
14.9%
1.7 pts better
|
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 | 0.8% |
3.1%
2.3 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.0% |
23.2%
2.2 pts better
|
19.8%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
4.6%
0.3 pts worse
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
75.6%
22.1 pts better
|
81.7%
16 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.4% |
11.7%
6.3 pts better
|
12.0%
6.6 pts better
|
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 | 92.9% |
73.5%
19.4 pts better
|
79.7%
13.2 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.1% |
23.0%
6.1 pts worse
|
23.9%
5.2 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-02-16
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2026-02-16
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-02-16
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-16
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-02-16
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2026-02-16
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-02-16
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2026-02-16
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2026-02-16
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-19
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-19
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-04-17
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-19
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-17
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-06-21
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-06-21
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-06-21
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-08
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 2025-12-08
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-08
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-12-08
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-12-08
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-12-08
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-12-08
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-12-08
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-29
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-29
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-02-29
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-02-29
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-02-29
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-05-31
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-05-31
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 2022-05-31
Penalties and ownership
5% Or Greater Mortgage Interest · Organization
Operational/Managerial Control · Individual
5% Or Greater Mortgage Interest · Individual
5% Or Greater Mortgage Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Nearby options
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Shawnee, KS
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