Your report for Hillside Village of de Soto Rehabilitation and Nur
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- KansasAbove only 40% of peers294 rated homes · average 3.0★
- Johnson CountyAbove only 44% of peers35 rated homes · average 2.7★
- United StatesAbove only 41% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point3★+0.2 vs KS avg
- StaffingCan add or remove a star2★−1.4 vs KS avg
- Quality measuresCan add or remove a star3★−0.1 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 cycles3★Above only 44% of 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 assessments3★Above only 35% 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 staff3.67hrsAbove only 32% 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 only0.63hrsAbove only 46% 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 better62%Above only 19% of peersKS avg50%RN turnover64%
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$0Above 50% of peersKS avg$21,017Fines · denials0 · 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 monthApr 2021 – Feb 2024
- 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.
Feb 20, 2024Cycle 1worst F · no actual harm
- 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 28, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Mar 28, 2024
- 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 Mar 28, 2024
- F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesF · widespreadCorrected Mar 28, 2024
- 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 Mar 28, 2024
Aug 2, 2022Cycle 2worst F · no actual harm
- 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 Sep 6, 2022
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Sep 6, 2022
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Sep 6, 2022
- Ensure each residentâs drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Sep 6, 2022
- F565Honor the resident's right to organize and participate in resident/family groups in the facility.Resident RightsE · patternCorrected Sep 6, 2022
- 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 PlanningE · patternCorrected Sep 6, 2022
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Sep 6, 2022
- 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 Sep 6, 2022
Apr 26, 2021Cycle 3worst E · no actual harm
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected May 11, 2021
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.67hrs
- Registered nursesRN hours only0.63hrs
- Licensed practical nursesLPN hours0.91hrs
- Nurse aidesCNA hours2.13hrs
- Weekend nursingAll staff on Saturdays and Sundays3.25hrs
- Kansas average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better62%Above only 19% of peersKS avg 50%
- RN turnoverRegistered nurses only64%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy49 certified beds · ~42 residents a day85%Above only 49% of peersKS avg 82%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $0In fines
- 0Fines
- 0Payment denials
- $21,017KS avg in fines
Actions on record
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Limited Liability company
- 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
- Corwin Lewis
- David Jorgensen
- Soon Burnam
- Craig Fitch
- Corwin Lewis
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 175472 · 33600 WEST 85TH STREET, DE SOTO, KS, 66018.
- 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.
