Overland Park, KS

Shawnee Post Acute Rehabilitation Center

1-star overall rating with 1-star inspections with $28,558 in total fines with 24 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

7600 Antioch Road, Overland Park, KS

(913) 383-2001

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

101

Certified beds

Average residents

89

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

The Ensign Group

Operator or chain grouping

Approved since

2015-11-19

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

329 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.40

Registered nurse staffing · state 0.72 · national 0.68

LPN hours / resident day

1.00

Licensed practical nurse staffing · state 0.67 · national 0.87

Aide hours / resident day

2.39

Nurse aide staffing · state 2.69 · national 2.35

Total nurse hours

3.79

All reported nurse hours · state 4.07 · national 3.89

Licensed hours

1.40

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

3.43

Weekend nurse staffing · state 3.58 · national 3.43

Weekend RN hours

0.15

Weekend registered nurse coverage · state 0.50 · national 0.47

Physical therapist

0.14

Reported PT staffing · state 0.04 · national 0.07

Adjusted RN hours

0.38

CMS adjusted RN staffing hours

Adjusted total hours

3.57

CMS adjusted total nurse staffing hours

Case-mix index

1.45

Higher values indicate more complex resident acuity

RN turnover

50%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

52%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,009

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

25.01

Composite VBP score used to determine payment impact.

Payment multiplier

0.9837

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.41

Baseline 22.11% · Performance 20.12% · Measure score 3.41 · Achievement 2.83 · Improvement 3.41

Healthcare-associated infections

2.57

Baseline 5.91% · Performance 7.07% · Measure score 2.57 · Achievement 2.57 · Improvement 0

Total nurse turnover

1.07

Baseline 60.24% · Performance 59.30% · Measure score 1.07 · Achievement 1.07 · Improvement 0

Adjusted total nurse staffing

2.95

Baseline 4.08 hours · Performance 3.92 hours · Measure score 2.95 · Achievement 2.95 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 11.38%
10.72%
0.7 pts worse
No Different than the National Rate · Eligible stays 128 · Observed rate 14.06% · Lower 95% interval 7.85%
Discharge to community 56.11%
50.57%
5.5 pts better
No Different than the National Rate · Eligible stays 108 · Observed rate 49.07% · Lower 95% interval 47.59%
Medicare spending per beneficiary 0.89
1.02
0.1 pts better
Drug regimen review with follow-up 70.15%
95.27%
25.1 pts worse
Numerator 47 · Denominator 67
Falls with major injury 0%
0.77%
0.8 pts better
Numerator 0 · Denominator 67
Discharge self-care score 63.64%
53.69%
10 pts better
Numerator 28 · Denominator 44
Discharge mobility score 54.55%
50.94%
3.6 pts better
Numerator 24 · Denominator 44
Pressure ulcers or injuries, new or worsened 0%
2.29%
2.3 pts better
Numerator 0 · Denominator 67 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization 7.07%
7.12%
About the same
No Different than the National Rate · Eligible stays 75 · Observed rate 8% · Lower 95% interval 4.38%
Staff COVID-19 vaccination coverage 0%
8.2%
8.2 pts worse
Numerator 0 · Denominator 148
Staff flu vaccination coverage 19.57%
42%
22.4 pts worse
Numerator 45 · Denominator 230
Discharge function score 65.91%
56.45%
9.5 pts better
Numerator 29 · Denominator 44
Transfer of health information to provider 84.62%
95.95%
11.3 pts worse
Numerator 22 · Denominator 26
Transfer of health information to patient 100%
96.28%
3.7 pts better
Numerator 22 · Denominator 22
Resident COVID-19 vaccinations up to date 65.52%
25.2%
40.3 pts better
Numerator 19 · Denominator 29

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 2.1
1.8
0.3 pts worse
1.9
0.2 pts worse
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.9 · Expected 1.8 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 1.6
2.2
0.6 pts better
1.8
0.2 pts better
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.6 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 97.6%
91.8%
5.8 pts better
93.4%
4.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 97.3% · Q3 98.5% · Q4 96.1% · 4Q avg 97.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 97.5%
95.5%
2 pts better
95.5%
2 pts better
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.5%
Percentage of long-stay residents experiencing one or more falls with major injury 3.1%
4.4%
1.3 pts better
3.3%
0.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.4% · Q3 4.5% · Q4 3.9% · 4Q avg 3.1% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 12.4%
5.6%
6.8 pts worse
11.4%
1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 6.5% · Q3 13.1% · Q4 11.9% · 4Q avg 12.4%
Percentage of long-stay residents who lose too much weight 1.5%
5.0%
3.5 pts better
5.4%
3.9 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 17.3%
23.2%
5.9 pts better
19.6%
2.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 17.1% · Q3 16.1% · Q4 18.6% · 4Q avg 17.3%
Percentage of long-stay residents who received an antipsychotic medication 11.3%
19.8%
8.5 pts better
16.7%
5.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 12.1% · Q3 5.9% · Q4 10.7% · 4Q avg 11.3% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened 5.6%
18.4%
12.8 pts better
16.3%
10.7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 0.0% · Q3 10.7% · Q4 3.4% · 4Q avg 5.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 10.0%
18.8%
8.8 pts better
14.9%
4.9 pts better
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 15.2% · Q3 8.8% · Q4 9.5% · 4Q avg 10.0% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 2.4% · 4Q avg 1.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 0.4%
3.1%
2.7 pts better
1.7%
1.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 22.1%
23.2%
1.1 pts better
19.8%
2.3 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 23.7% · Q3 11.8% · Q4 29.0% · 4Q avg 22.1%
Percentage of long-stay residents with pressure ulcers 5.8%
4.6%
1.2 pts worse
5.1%
0.7 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 4.5% · Q3 5.0% · Q4 6.6% · 4Q avg 5.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 79.8%
75.6%
4.2 pts better
81.7%
1.9 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 84.4% · Q2 82.4% · Q3 78.3% · Q4 74.2% · 4Q avg 79.8%
Percentage of short-stay residents who had an outpatient emergency department visit 10.9%
11.7%
0.8 pts better
12.0%
1.1 pts better
Short Stay · 20240701-20250630 · Adjusted 10.9% · Observed 10.9% · Expected 11.2% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 1.5%
2.2%
0.7 pts better
1.6%
0.1 pts better
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 0.0% · Q4 3.8% · 4Q avg 1.5% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 72.3%
73.5%
1.2 pts worse
79.7%
7.4 pts worse
Short Stay · 2024Q3-2025Q2 · 4Q avg 72.3%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 27.2%
23.0%
4.2 pts worse
23.9%
3.3 pts worse
Short Stay · 20240701-20250630 · Adjusted 27.2% · Observed 25.5% · Expected 22.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-03-27 · Fire 2024-03-27

24 health deficiencies

Top issue: Quality of Life and Care (7 deficiencies)

8 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2022-10-05 · Fire 2022-10-05

10 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

4 fire-safety deficiencies

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

Cycle 3 Health 2021-05-13 · Fire 2021-05-13

6 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

2 fire-safety deficiencies

Top issue: Services (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-03-27

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 2024-04-30

F · Potential for more than minimal harm 2024-03-27

K343 · Smoke Deficiencies

Fire Safety

Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

Corrected 2024-04-30

F · Potential for more than minimal harm 2024-03-27

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-04-30

F · Potential for more than minimal harm 2024-03-27

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2024-05-02

F · Potential for more than minimal harm 2024-03-27

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-05-02

E · Potential for more than minimal harm 2024-03-27

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-05-02

D · Potential for more than minimal harm 2024-03-27

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-05-02

D · Potential for more than minimal harm 2024-03-27

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-05-02

F · Potential for more than minimal harm 2022-10-05

K343 · Smoke Deficiencies

Fire Safety

Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

Corrected 2022-12-01

F · Potential for more than minimal harm 2022-10-05

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2022-12-01

D · Potential for more than minimal harm 2022-10-05

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2022-12-01

D · Potential for more than minimal harm 2022-10-05

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2022-12-01

E · Potential for more than minimal harm 2021-05-13

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2021-07-25

E · Potential for more than minimal harm 2021-05-13

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2021-07-25

Inspection history

Recent health citations

G · Actual harm 2024-03-27

F692 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-04-23

F · Potential for more than minimal harm 2024-03-27

F801 · Nutrition and Dietary Deficiencies

Health

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Corrected 2024-04-23

F · Potential for more than minimal harm 2024-03-27

F941 · Administration Deficiencies

Health

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Corrected 2024-04-23

F · Potential for more than minimal harm 2024-03-27

F942 · Resident Rights Deficiencies

Health

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Corrected 2024-04-23

F · Potential for more than minimal harm 2024-03-27

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 2024-04-23

E · Potential for more than minimal harm 2024-03-27

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-04-23

E · Potential for more than minimal harm 2024-03-27

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-04-23

D · Potential for more than minimal harm 2024-03-27

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-04-23

D · Potential for more than minimal harm 2024-03-27

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2024-04-23

D · Potential for more than minimal harm 2024-03-27

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2024-04-23

D · Potential for more than minimal harm 2024-03-27

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2024-04-23

D · Potential for more than minimal harm 2024-03-27

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 2024-04-23

D · Potential for more than minimal harm 2024-03-27

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-04-23

D · Potential for more than minimal harm 2024-03-27

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2024-04-23

D · Potential for more than minimal harm 2024-03-27

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 2024-04-23

D · Potential for more than minimal harm 2024-03-27

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 2024-04-23

D · Potential for more than minimal harm 2024-03-27

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2024-04-23

D · Potential for more than minimal harm 2024-03-27

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 2024-04-23

D · Potential for more than minimal harm 2024-03-27

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-04-23

D · Potential for more than minimal harm 2024-03-27

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-04-23

D · Potential for more than minimal harm 2024-03-27

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2024-04-23

D · Potential for more than minimal harm 2024-03-27

F849 · Administration Deficiencies

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 2024-04-23

D · Potential for more than minimal harm 2024-03-27

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-04-23

D · Potential for more than minimal harm 2024-03-27

F883 · Infection Control Deficiencies

Health

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

Corrected 2024-04-23

D · Potential for more than minimal harm 2023-11-20

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2023-11-30

D · Potential for more than minimal harm 2023-05-02

F676 · Quality of Life and Care Deficiencies

Health

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected 2023-06-02

D · Potential for more than minimal harm 2023-05-02

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2023-06-02

G · Actual harm 2022-10-05

F692 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-11-03

E · Potential for more than minimal harm 2022-10-05

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2022-11-03

E · Potential for more than minimal harm 2022-10-05

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2022-11-03

D · Potential for more than minimal harm 2022-10-05

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2022-11-03

D · Potential for more than minimal harm 2022-10-05

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-11-03

D · Potential for more than minimal harm 2022-10-05

F740 · Quality of Life and Care Deficiencies

Health

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected 2022-11-03

D · Potential for more than minimal harm 2022-10-05

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 2022-11-03

D · Potential for more than minimal harm 2022-10-05

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2022-11-03

D · Potential for more than minimal harm 2022-10-05

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 2022-11-03

D · Potential for more than minimal harm 2022-10-05

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2022-11-03

D · Potential for more than minimal harm 2021-05-13

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2021-06-07

D · Potential for more than minimal harm 2021-05-13

F676 · Quality of Life and Care Deficiencies

Health

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected 2021-06-07

D · Potential for more than minimal harm 2021-05-13

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 2021-06-07

Penalties and ownership

What sits behind the stars

$28,558 2024-03-27

Fine

Fine · fine $28,558

Fine

Ownership

Burnam, Soon

Corporate Officer · Individual

0% 323 facilities 2014-01-28
Geha, Christopher

Operational/Managerial Control · Individual

0% 4 facilities 2023-07-01
Jimenez, Luis

Operational/Managerial Control · Individual

0% 1 facilities 2019-09-26
Keetch, Chad

Corporate Officer · Individual

0% 176 facilities 2011-03-01
Lewis, Corwin

Corporate Officer · Individual

0% 10 facilities 2021-06-01
Sato, Ami

Corporate Officer · Individual

0% 101 facilities 2024-09-09

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#3

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Fines
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