Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- KansasAbove only 22% of peers294 rated homes · average 3.0★
- Johnson CountyAbove only 29% of peers35 rated homes · average 2.7★
- United StatesAbove only 20% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point1★−1.8 vs KS avg
- StaffingCan add or remove a star2★−1.4 vs KS avg
- Quality measuresCan add or remove a star5★+1.9 vs KS avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersKS avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover2★Above only 12% of peersKS avg3.4★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above 81% of peersKS avg3.1★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff3.76hrsAbove only 39% of peersKS avg4.07Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.81hrsAbove 69% of peersKS avg0.71Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better63%Above only 18% of peersKS avg50%RN turnover62%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$132,837Above only 2% of peersKS avg$21,017Fines · denials24 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthJan 2022 – Jun 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Jun 26, 2025Cycle 1worst F · no actual harm
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Aug 7, 2025
- F881Implement a program that monitors antibiotic use.Infection ControlF · widespreadCorrected Aug 7, 2025
- F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.AdministrationD · isolatedCorrected Aug 7, 2025
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected Aug 7, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Aug 7, 2025
- Ensure each residentâs drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Aug 7, 2025
- F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Resident RightsD · isolatedCorrected Aug 7, 2025
- F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Aug 7, 2025
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Aug 7, 2025
- F565Honor the resident's right to organize and participate in resident/family groups in the facility.Resident RightsE · patternCorrected Aug 7, 2025
- F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Resident RightsD · isolatedCorrected Aug 7, 2025
- F637Assess the resident when there is a significant change in conditionResident Assessment and Care PlanningD · isolatedCorrected Aug 7, 2025
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Aug 7, 2025
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Aug 7, 2025
- F679Provide activities to meet all resident's needs.Quality of Life and CareE · patternCorrected Aug 7, 2025
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Aug 7, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Aug 7, 2025
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareE · patternCorrected Aug 7, 2025
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Aug 7, 2025
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesF · widespreadCorrected Aug 7, 2025
Jan 13, 2025Cycle 2worst G · actual harm$17,940
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareG · isolatedCorrected Feb 12, 2025
Jul 3, 2024Cycle 2worst G · actual harm$15,041
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected Jul 29, 2024
Mar 12, 2024Cycle 2worst E · no actual harm
- F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Resident RightsE · patternCorrected Apr 12, 2024
- F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.AdministrationE · patternCorrected Apr 12, 2024
Nov 29, 2023Cycle 3worst G · actual harm$4,587, $4,587, $4,587
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Dec 20, 2023
Oct 19, 2023Cycle 2worst F · no actual harm$4,587, $4,587, $4,587, $4,587, $4,587
- F758Implement 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.Pharmacy ServiceD · isolatedCorrected Nov 28, 2023
- Notify the resident or the residentâs representative in writing how long the nursing home will hold the residentâs bed in cases of transfer to a hospital or therapeutic leave.Resident RightsD · isolatedCorrected Nov 28, 2023
- F732Post nurse staffing information every day.Nursing and Physician ServicesC · widespreadCorrected Nov 28, 2023
- F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident RightsE · patternCorrected Nov 28, 2023
- F585Honor 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.Resident RightsE · patternCorrected Nov 28, 2023
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Nov 28, 2023
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Nov 28, 2023
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Nov 28, 2023
- F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesF · widespreadCorrected Nov 28, 2023
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected Nov 28, 2023
- F761Ensure 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.Pharmacy ServiceE · patternCorrected Nov 28, 2023
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Nov 28, 2023
- F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.AdministrationF · widespreadCorrected Nov 28, 2023
- F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyAdministrationF · widespreadCorrected Nov 28, 2023
- F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Nov 28, 2023
- F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Infection ControlF · widespreadCorrected Nov 28, 2023
- F920Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.EnvironmentalE · patternCorrected Nov 28, 2023
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalE · patternCorrected Nov 28, 2023
- F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Nursing and Physician ServicesF · widespreadCorrected Nov 28, 2023
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected Nov 28, 2023
Aug 7, 2023Cycle 3worst D · no actual harm$4,587, $4,587, $4,587, $4,587
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Sep 5, 2023
Jun 19, 2023Cycle 3worst D · no actual harm$3,529, $3,176, $2,823, $2,470
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Jul 19, 2023
- Ensure each residentâs drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Jul 19, 2023
Jan 27, 2022Cycle 3worst E · no actual harm
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Mar 2, 2022
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Mar 2, 2022
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Mar 2, 2022
- F758Implement 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.Pharmacy ServiceD · isolatedCorrected Mar 2, 2022
- F761Ensure 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.Pharmacy ServiceE · patternCorrected Mar 2, 2022
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Mar 2, 2022
- F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.AdministrationD · isolatedCorrected Mar 2, 2022
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareE · patternCorrected Mar 2, 2022
- F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Resident RightsD · isolatedCorrected Mar 2, 2022
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.76hrs
- Registered nursesRN hours only0.81hrs
- Licensed practical nursesLPN hours0.52hrs
- Nurse aidesCNA hours2.42hrs
- Weekend nursingAll staff on Saturdays and Sundays3.27hrs
- Kansas average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better63%Above only 18% of peersKS avg 50%
- RN turnoverRegistered nurses only62%Not ranked by CMS
- Administrators who leftIn the past year2Leadership changed
- Occupancy102 certified beds · ~62 residents a day61%Above only 8% of peersKS avg 82%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $132,837In fines
- 24Fines
- 0Payment denials
- $21,017KS avg in fines
Actions on record
- Jan 13, 2025Civil money penalty$17,940
- Jul 3, 2024Civil money penalty$15,041
- Nov 20, 2023Civil money penalty$4,587
- Nov 13, 2023Civil money penalty$4,587
- Nov 6, 2023Civil money penalty$4,587
- Oct 30, 2023Civil money penalty$4,587
- Oct 23, 2023Civil money penalty$4,587
- Oct 17, 2023Civil money penalty$4,587
- Oct 10, 2023Civil money penalty$4,587
- Oct 2, 2023Civil money penalty$4,587
- Sep 25, 2023Civil money penalty$4,587
- Sep 18, 2023Civil money penalty$4,587
- Sep 11, 2023Civil money penalty$4,587
- Aug 28, 2023Civil money penalty$4,587
- Aug 21, 2023Civil money penalty$4,587
- Aug 14, 2023Civil money penalty$4,587
- Aug 7, 2023Civil money penalty$4,587
- Jul 17, 2023Civil money penalty$12,703
- Jun 26, 2023Civil money penalty$3,529
- Jun 20, 2023Civil money penalty$3,176
- Jun 12, 2023Civil money penalty$2,823
- Jun 5, 2023Civil money penalty$2,470
- May 30, 2023Civil money penalty$2,117
- May 8, 2023Civil money penalty$4,233
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Corporation
- Chain
- The Ensign Group324 facilities in the chain3.2★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Gateway Healthcare LLC
- The Ensign Group INC
- Jacqueline Hollis
- David Jorgensen
- Soon Burnam
- Craig Fitch
- Corwin Lewis
- Ami Sato
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 175187 · 6501 W 75TH STREET, OVERLAND PARK, KS, 66204.
- Percentiles compare this facility with every rated nursing home in Kansas and Johnson County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.









