21250 West 151st Street, Olathe, KS 66061 · Johnson County · (913) 390-0444
70 certified beds, about 55 residents a day · For profit - Corporation · Medicare and Medicaid since 2016
CMS Care Compare ratings, data as of September 1, 2026 · CCN 175551 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on April 16, 2025, inspectors cited 13 health deficiencies (the Kansas average is 9.5, the national average 9.2).
Of 58 health citations since December 2021, 5 were rated as actual harm or immediate jeopardy to residents (3 immediate jeopardy).
CMS lists 3 fines totaling $37,417 in the last three years; the largest was $17,345, and the latest is dated January 23, 2025.
Nurses and nurse aides worked 3.99 hours per resident per day, against 4.07 across Kansas and 3.86 nationally. Registered nurses accounted for 0.78 of those hours.
CMS links it to The Ensign Group, an affiliated group of 344 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 58 health citations on file.
Inspectors wroteThe facility reported a census of 57 residents. The sample included 15 residents. Based on record review and interviews, the facility failed to submit accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ - Staffing Data Report), when the facility failed to submit accurate weekend staffing hours. This placed the residents at risk for unidentified and ongoing inadequate staffing.
Inspectors wroteThe facility identified a census of 57 residents. The sample includes 15 residents. Based on observation, record review, and interviews, the facility failed to implement a system to allow residents and/or their representatives to file grievances anonymously. This deficient practice placed the residents at risk for decreased psychosocial well-being and unresolved grievances and concerns. Findings Included: - On 04/14/25 at 7:55 AM, an inspection of the facility revealed no designated grievance drop boxes or system available in the areas accessible to the residents and visitors of the facility. On 04/15/25 at 01:30 PM, the Resident Council members reported they were not aware if the facility provided a way to complete anonymous grievances. The council reported they must take the grievance to a staff member. The Resident Council stated the staff helped the residents fill out grievances. [...]
Inspectors wroteThe facility identified a census of 57 residents. The sample includes 15 residents. Based on observation, record review, and interviews, the facility failed to provide consistent weekend activities. This deficient practice placed the affected residents at risk for decreased psychosocial well-being.
Inspectors wrote- R28's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of edema (swelling resulting from an excessive accumulation of fluid in the body tissues), chronic kidney disease, congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), muscle weakness, need for assistance with personal care, and pain. The Annual Minimum Data Set (MDS) dated 06/17/24 documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R28 required partial to moderate assistance with toileting and mobility. The MDS also documented R28 required substantial to maximum assistance with bathing, lower extremity dressing, and transfers. The MDS documented R28 was at risk for the development of pressure ulcers and placed pressure-reducing devices on her bed and in her chair. [...]
Inspectors wroteThe facility reported a census of 57 residents. The facility identified two medication rooms and four medication carts. Based on observations, record reviews, and interviews, the facility failed to secure one of four medication carts. This deficient practice placed the residents at risk for unnecessary medication and administration errors. Findings Included: - On 04/14/25 at 07:26 AM, an inspection of the west wing was completed. The west wing inspection revealed an unsecured medication cart next to the oxygen storage room revealed prescribed medications, ointments, and treatment care supplies accessible without staff supervision. On 04/14/25 at 07:30 AM, Certified Medication Aide (CMA) R came around the corner from the medication storage area and secured the cart. She stated the carts were to be locked when not supervised. [...]
Inspectors wroteThe facility identified a census of 57 residents. The facility identified 17 residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record reviews, observations, and interviews, the facility failed to store Resident (R) 5, R9, and R37's respiratory equipment in a sanitary manner. The facility additionally failed to store clean linens in a sanitary manner and further failed to ensure R34's Foley catheter (a tube inserted into the bladder to drain urine into a collection bag) remained off the floor. These deficient practices placed the residents at risk for infectious diseases.
Inspectors wroteThe facility identified a census of 57 residents. The sample included 15 residents, with two residents reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure staff assisted Resident (R) 26 with cutting her whiskers per her preference. This deficient practice placed R26 at risk for impaired dignity and decreased psychosocial well-being. Findings Included: [...]
Inspectors wroteThe facility identified a census of 57 residents. The sample included 15 residents, with two reviewed for reasonable accommodation of needs related to assistive devices. Based on observation, record review, and interviews, the facility failed to ensure Residents (R) 37 and R42 had a way to communicate their needs due to their call lights being left out of reach. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings Included: - On 04/14/25 at 07:00 AM, an inspection of R37's (a physically impaired resident unable to self-transfer) room revealed her asleep in her bed. R37's call light was on the floor to the left side of her bed. On 04/15/25 at 07:37 AM, R42 (a cognitively and physically impaired resident unable to self-transfer) slept in her bed. Her bed remained in a low position. [...]
Inspectors wroteThe facility identified a census of 57 residents. The sample included 15 residents with three reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to implement a physician's order for a fluid restriction for Resident (R) 28. The facility also failed to ensure the physician's order was followed for a daily weight for R34 to monitor for congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). The facility failed to ensure the physician's order was followed to wrap R26's bilateral lower extremities. These deficient practices placed these residents at risk of delayed treatment and untreated illness.
Inspectors wroteThe facility identified a census of 57 residents. The sample included 15 residents, with five reviewed for accidents. Based on record review, interviews, and observations, the facility failed to ensure a safe care environment free from potential hazards related to following Residents (R) 50, R29, and R26's implemented fall interventions. This deficient practice placed the residents at risk for preventable falls and injuries. Findings Included: - The Medical Diagnosis section within R50's Electronic Medical Records (EMR) noted diagnoses of senile degeneration of the brain (a progressive mental disorder characterized by failing memory and confusion), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and overactive bladder. [...]
Inspectors wroteThe facility identified a census of 57 residents. The sample included 15 residents, with two residents reviewed for catheters (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). Based on observation, record review, and interviews, the facility failed to ensure the standard of care was provided for Resident (R) 34 who had a history of urinary tract infection (UTI - an infection in any part of the urinary system) when her catheter drainage bag laid directly on the floor. This deficient practice placed R34 at risk of catheter-related complications and further UTIs.
Inspectors wroteThe facility identified a census of 57 residents. The sample included 15 residents, with five residents reviewed for unnecessary medications. Based on record review and interviews, the facility failed to ensure dosing instructions for Voltaren (topical pain reliever medication) gel for Resident (R) 28. This deficient practice placed R28 at risk for unnecessary medication use and physical complications for the affected residents.
Inspectors wroteThe facility identified a census of 57 residents. The sample included 15 residents, with one resident reviewed for a therapeutic diet. Based on observation, record review, and interviews, the facility failed to implement a therapeutic diet as ordered by the physician order for Resident (R) 28, who had a diagnosis of congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). This deficient practice placed R28 at risk of adverse side effects from unnecessary medication or complications related to CHF.
Inspectors wroteThe facility identified a census of 59 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 1 remained free from neglect. On 01/15/25 between 08:00 PM and 09:00 PM, R1 propelled himself in his wheelchair to the bathroom. He reached for the grab bar beside the toilet and the momentum of that action caused him to slip from his wheelchair and fall to the right, into the walk-in shower. R1 laid on the floor, unable to move or reach the call light beside the toilet. R1 remained on the floor until Licensed Nurse (LN) G discovered him on 01/16/25 at approximately 05:10 AM when she entered his room to empty his catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) bag. R1 told LN G he hit his head and he complained of right rib pain. [...]
Inspectors wroteThe facility identified a census of 62 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to provide adequate staff response to door alarms to prevent cognitively impaired and independently mobile Resident (R)1 from eloping from the facility. On 09/11/24 at 07:26 AM R1 pressed the release bar on the northwest emergency exit door for 15 seconds, opened the door, and exited the facility. The door alarm sounded but no staff responded, therefore, staff were unaware R1 exited the facility. R1 wheeled herself down the sidewalk of the rear parking lot. Therapy Consultant GG arrived for work around 07:32 AM and observed R1 outside near the facility dumpsters on the northwest side of the building and alerted facility staff. Staff assisted R1 back inside the facility and assessed for injuries though none were noted. [...]
Inspectors wroteThe facility identified a census of 62 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to identify an elopement for Resident (R) 1 as potential neglect and report to the State Agency (SA) as required. This placed R1 at risk for unidentified and ongoing neglect. Findings Included: - R1's Electronic Medical Record (EMR) documented diagnosis of Alzheimer's Disease (progressive mental deterioration characterized by confusion and memory failure), altered mental status, dementia (progressive mental disorder characterized by failing memory, confusion), generalized muscle weakness, repeated falls, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and a need for assistance with personal care. [...]
Inspectors wroteThe facility identified a census of 69 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 1 remained free from neglect. On 07/22/24, R1, who was cognitively intact but diabetic (individual with a chronic disease that results in too much glucose in the blood), legally blind, and had bilateral lower extremity amputations (surgical removal of a limb), wheeled himself outside around 08:00 PM without letting staff know and without his cell phone. R1 tipped over in his wheelchair and was unable to get up or contact staff for assistance. R1 laid on the ground and called out for staff to assist him though no one came to help. R1 remained outside on the ground from around 08:00 PM on 07/22/24 until early the next morning. [...]
Inspectors wroteThe facility identified a census of 59 residents. The sample included three residents. Based on observation, record review, and interview the facility failed to ensure Resident (R) 1 remained free from verbal abuse when staff made inappropriate statements to R1. On 05/16/24 Certified Nurse Aide (CNA) M became irritated with R1 and made disparaging remarks about the size of R1's genitals. This placed R1 at risk for impaired psychosocial well-being including humiliation and degradation.
Inspectors wroteThe facility identified a census of 59 residents. The sample included three residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure staff identified an incident as verbal abuse and reported the incident to the Administrator immediately. This deficient practice created the risk of unidentified and ongoing abuse.
Inspectors wroteThe facility identified a census of 59 residents. The sample included three residents. Based on observation, record review, and interview the facility failed to ensure Resident (R) 1 received the required assistance with activities of daily living (ADL). This placed R1 at risk for skin breakdown, poor hygiene, and impaired psychosocial well-being.
Inspectors wroteThe facility identified a census of 63 residents. The sample included three residents reviewed for care medications used. Based on record review, observation, and interview, the facility failed to revise the comprehensive care plan for resident R1's use of an injectable medication for a diagnosed skin condition. This placed R1 at risk for impaired care related to uncommunicated care needs.
Inspectors wroteThe facility identified a census of 63 residents. The sample included three residents reviewed for medications. Based on record review, observation, and interviews, the facility failed to prevent a significant medication error when Resident (R)1 did not receive a scheduled injectable medication for the treatment of psoriasis (a chronic, sometimes painful skin disease that causes a rash with itchy, scaly patches, on the knees, elbows, trunk, and scalp). On 01/21/24, after an inquiry from R1's representative, it was identified R1's quarterly injection was overdue by 40 days. This placed R1 at risk for decreased therapeutic effect of the medication and complications related to R1's skin disease.
Inspectors wroteThe facility identified a census of 69 residents. The sample included three residents reviewed for falls. Based on observations, record review, and interviews, the facility failed to follow fall interventions to prevent a fall with major injury for Resident (R) 1. On 09/16/23, Certified Nurse Aide (CNA) M forgot to place the fall mat on the floor, next to R1's bed. R1 was subsequently found on the floor with a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma), skin tear, and a right thumb fracture. The injuries resulting from the deficient practice also placed R1 at increased risk for pain.
Inspectors wroteThe facility identified a census of 69 residents. One resident was reviewed for abuse. Based on observations, record review, and interviews, the facility failed to ensure Resident (R) 1 received the necessary protective oversight to prevent potential abuse and/or neglect when the facility failed to report a fracture of unknown origin as potential abuse or neglect to the State Agency (SA), within the mandated time frame. This deficient practice placed R1 at risk for unresolved and ongoing abuse, a decrease in psychosocial well-being, and further injuries.
Inspectors wroteThe facility identified a census of 69 residents. One resident was reviewed for abuse. Based on observations, record review, and interviews, the facility failed to ensure Resident (R) 1 received the necessary protective oversight to prevent potential abuse and/or neglect when the facility failed to investigate a fracture of unknown origin as potential abuse or neglect and send the completed investigation to the State Agency (SA) within the required timeframe. This deficient practice placed R1 at risk for unresolved and ongoing abuse, a decrease in psychosocial well-being, and further injuries.
Inspectors wroteThe facility identified a census of 69 residents. Three residents were reviewed for weight loss. Based on observations, record review, and interviews, the facility failed to follow recommendations from the dietitian and failed to provide consistent weight loss interventions for Resident (R) 1 who had a significant weight loss of 16.3% from 08/14/23 to 10/09/23. This deficient practice placed R1 at risk for further weight loss and physical complications.
Inspectors wroteThe facility identified a census of 61 residents. The sample include 15 residents. Based on observation, record review, and interviews, the facility failed to implement a system to allow residents and/or their representatives to file grievances anonymously. This deficient practice placed the residents at risk for decreased psychosocial wellbeing. Findings Included: - On 08/08/23 at 11:50 AM during Resident Council, Resident (R)22 stated that he was not aware of a way to file a grievance without staff assistance/anonymously. On 08/09/23 at 11:26 AM Activity Z stated residents reported grievances to her, but she was not aware of a way that residents, or families, could file a grievance anonymously. On 08/09/23 at 02:50 PM Licensed Nurse (LN) J stated that grievance forms were in a folder at the desks/nurse's stations on each hall and residents could ask staff for the forms. [...]
Inspectors wroteThe facility identified a census of 61 residents. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to provide resident-centered activities for cognitively impaired residents on weekends. This deficient practice placed eight cognitively impaired residents at risk for decreased psychosocial wellbeing. Findings Included: - The facility's Activity Calendar for June, July, and August of 2023 revealed Movie Matinee at 02:00PM on Saturdays and Independent Game Groups on Sundays. The Calendars had no staff led activities noted on the weekends. On 08/08/23 at 01:00PM, the Resident Council reported the facility did not provide staff-led activities on the weekends. The council reported residents could complete independent games and puzzles provided by the facility. [...]
Inspectors wroteThe facility identified a census of 61 residents with one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to storage of food. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns.
Inspectors wroteThe facility identified a census of 51 residents. The sample included 15 residents. Based on record review, observations, and interviews, the facility failed to maintain sanitary infection control practices related to the storage of oxygen therapy equipment, performing hand hygiene during cares, and sanitization of shared equipment. This deficient practice placed the residents at risk for complications related to infectious diseases. Findings Included: - On 08/07/23 at 09:31AM, Licensed Nurse (LN) J did not sanitize a shared blood pressure cuff before using it on different residents. On 08/07/23 at 10:44AM, R37's continuous positive airway pressure (CPAP- mask used to treat sleep disturbances) mask was on the floor in his room with the face side down touching the floor. R37 reported he was not sure why the mask was on the floor. No storage bag was in the room. [...]
Inspectors wroteThe facility identified a census of 61 residents. The sample included 15 residents with one resident reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 103's window blinds/curtain that open to a street was closed during peri-care and wound treatment to coccyx area. This deficient practice placed R103 at risk for impaired dignity and decreased psychosocial well-being.
Inspectors wroteThe facility identified a census of 61 residents and the sample included 15 residents. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)31's call light was within reach. This deficient practice placed R31 at risk for preventable accidents and injuries. Findings Included: - The electronic medical record (EMR) for R31 documented diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following a cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting right dominant side, speech and language deficits following cerebral infarction, and generalized muscle weakness. [...]
Inspectors wroteThe facility identified a census of 61 residents. The sample included 15 residents with two residents reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide a written notification of transfers with the required information to Resident (R)18 or to their family/durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to) in a practicable amount of time for a facility-intiated transfer. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for R18.
Inspectors wroteThe facility identified a census of 61 residents. The sample included 15 with two reviewed for bed holds. Based on record review, observations, and interviews, the facility failed to provide a bed hold for Resident (R)202 when hospitalized . This deficient practice placed R202 at risk of delayed care or uninformed choices. Findings Included: - The Medical Diagnosis section within R202's Electronic Medical Records (EMR) included chronic kidney disease, type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), congestive heart failure (a condition with low heart output and the body becomes congested with fluid), dementia (progressive mental disorder characterized by failing memory, confusion), and dysphagia (swallowing difficulty). A review of R202's EMR revealed she admitted on [DATE]. [...]
Inspectors wroteThe facility identified a census of 61 residents. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to develop person-centered comprehensive care plan for Resident (R) 104 related to her ability to participate in activities of daily living (ADLs) and storage /use of her nebulizer (an electrically powered machine that turns liquid medication into a mist so that it can be breathed directly into the lungs through a face mask or mouthpiece) mouthpiece. This deficient practice placed R104 at risk of lack of care related to ADL's, possible injuries, skin breakdown, uncommunicated needs, or possible further respiratory infections.
Inspectors wroteThe facility identified a census of 61 residents. The sample included 15 residents with 15 reviewed for care plan revisions. Based on observations, interviews, and record reviews, the facility failed to revise Resident (R)27's care plan to reflect her timed toileting schedule. This deficient practice placed R27 at risk for complications related to uncommunicated care needs. Finding Included: [...]
Inspectors wrote- R104's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), pneumonia (inflammation of the lungs), muscle weakness, and need for care with personal care. The admission Minimum Data Set (MDS) dated [DATE] documented cognition was not assessed. The MDS documented that R104 was dependent on two staff members assistance for activities of daily living (ADLs). The MDS documented the activity of bathing had occurred during the look back period for R104. [...]
Inspectors wroteThe facility identified a census of 61 residents. The sample included 15 residents with three residents reviewed for pressure ulcer/injury (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure reducing measures were placed on Resident (R) 104's bilateral lower extremities to prevent pressure ulcers. The facility also failed to ensure R103's pressure reducing boots on when in bed and to ensure staff implemented appropriate infection control practices during wound care, who was on an antibiotic (medication used to treat bacterial infections). This placed these residents at increased risk for pressure ulcer development and worsening of current wounds.
Inspectors wroteThe facility identified a census of 61 residents. The sample included 15 residents with five reviewed for accidents/falls. Based on observations, interviews, and record reviews, the facility failed to identify causative factors and implement fall interventions related to Resident (R)27's non-injury fall. This deficient practice placed R27 at risk for further falls and injuries. Finding Included: [...]
Inspectors wroteThe facility identified a census of 61 residents. The sample included 15 residents with five residents reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to store Resident (R) 104's nebulizer (an electrically powered machine that turns liquid medication into a mist so that it can be breathed directly into the lungs through a face mask or mouthpiece) mouthpiece in a sanitary manner. This deficient practice placed R104, who was being treated for pneumonia (inflammation of the lungs), at increased risk to develop other respiratory infections or delay of recovery.
Inspectors wroteThe facility identified a census of 61 residents. The sample included 15 residents with five sampled for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported Resident (R)16's Zyprexa (anti-psychotic -class of medications used to treat psychosis and other mental emotional conditions) medication had an appropriate indication for use, or the required physician documentation. This deficient practice placed R16 at risk of unnecessary psychotropic (alters mood or thought) medication administration and possible adverse side effects.
Inspectors wroteThe facility identified a census of 61 residents. The sample included 15 residents with five reviewed for unnecessary medications. Based on observations, record review, and interviews, the facility failed to ensure ordered parameters were followed for Resident (R) 11's antihypertensive medications (medications used to treat high blood pressure). This deficient practice had the risk for physical complications and unnecessary medication usage.
Inspectors wroteThe facility identified a census of 61 residents. The sample included 15 residents with five sampled for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure Resident (R)16's Zyprexa (antipsychotic -a class of medications used to treat psychosis and other mental emotional conditions) medication had an appropriate indication for use, or the required physician documentation. This deficient practice placed R16 at risk of unnecessary psychotropic (alters mood or thought) medication administration and possible adverse side effects.
Inspectors wroteThe facility identified a census of 61 residents. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 104 was free from medication errors when twelve medications were crushed and mixed together then administered via percutaneous endoscope gastrostomy (PEG-a tube inserted through the wall of the abdomen directly into the stomach) without a physician order. This deficient practice placed R104 at risk for increased complications and adverse side effects related medication interaction.
Inspectors wroteThe facility identified a census of 61 residents. The sample included 15 residents with two residents reviewed for hospice and end of life care. Based on observation, record review, and interviews, the facility failed to collaborate with hospice to determine and direct the services, medication, and equipment provided to Resident (R)34 by hospice services. This deficient practice created a risk for missed opportunities for services and delayed treatment.
Inspectors wroteThe facility identified a census of 61 residents. The sample included 15 residents. Based on record review, and interviews, the facility failed to provide mail services on Saturdays.
Inspectors wroteThe facility identified a census of 61 residents. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to post the previous state inspection information in a location accessible to residents and visitors, which placed the residents at risk for impaired rights.
Inspectors wroteThe facility identified a census of 66 residents. The sample included 18 residents. Based on observation, interview, and record review the facility failed to monitor hot liquid temperatures and failed to properly assess and ensure resident (R)9 was able to independently handle and drink hot liquids safely, which resulted in R9 receiving second degree burns when she spilled hot tea on herself.
Inspectors wroteThe facility identified a census of 66 residents. The sample included 18 residents with 10 residents reviewed for activities of daily living (ADLs). Based on observations, record reviews, and interviews, the facility failed to provide consistent bathing per the residents ' preferences and bathing schedules for Residents (R) 28, R32, R9, R16, R55, R18, R20, R31, R37, and R48. This placed the residents at risk for poor hygiene and decreased self-esteem.
Inspectors wroteThe facility identified a census of 66 residents with 18 residents sampled. Based on observations, record reviews, and interviews, the facility failed to ensure appropriate hand hygiene during meal pass and failed to ensure sanitary laundry handling. This deficient practice increased the risk of the spread of illness and infection to the residents. Findings Include: - On 12/27/21 at 09:35 AM an unidentified nursing staff carried a resident's blanket to the resident's room and allowed the blanket to drag on the floor past the nurse's station. Observation on 12/28/21 at 10:00 AM revealed the laundry cart containing clean linen sat in the west hallway, uncovered and unattended. On 12/28/21 at 12:30 PM kitchen staff served plates to several residents in the west dining room. [...]
Inspectors wroteThe facility identified a census of 66 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to ensure R31 choice was honored for his preferred bathing schedule and choice of bathing, which placed the resident at risk for negative psychosocial impact and increased feelings of shame and worthlessness.
Inspectors wroteThe facility identified a census of 66 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to provide a sanitary and comfortable, homelike environment for Resident (R)45. This placed R45 at risk for impaired psychosocial wellbeing. Findings Include: - The electronic medical record (EMR) documented the following diagnoses for R45: [...]
Inspectors wroteThe facility identified a census of 66 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to obtain weekly weights for Resident (R) 3 who had an unintended weight loss, which had the potential for physical complications related to nutritional deficits.
Inspectors wroteThe facility identified a census of 66 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to provide respiratory services per the standards of practice when staff failed to store oxygen (O2) tubing (device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) and store/clean the equipment for bilevel positive airway pressure (BiPAP/BPAP -a ventilation device used to treat sleep apnea [disorder of sleep characterized by periods without respirations], that uses mild air pressure to keep airways open during sleep) for R20. This deficient practice placed R20 at increased risk for development of respiratory complications.
Inspectors wroteThe facility identified a census of 66 residents. The sample included 18 residents. Five residents were reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities for R37's hypertensive medication (class of medication used to treat hypertension (high blood pressure) given outside the physician ordered parameters, which had the potential of unnecessary medication administration thus leading to possible harmful side effects.
Inspectors wroteThe facility identified a census of 66 residents. The sample included 18 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to follow a physician order for Resident (R) 20 and failed to hold antihypertensive (class of medication used to treat high blood pressure ) medication when indicated by the parameters set by the physician for R37. This deficient practice had the potential for unnecessary medication use and possible unwarranted side effects.
Inspectors wroteThe facility identified a census of 66 residents. The sample included 18 residents with one resident reviewed for food concerns. Based on observations, record reviews, and interviews, the facility failed to review Resident (R) 45's indicated allergies and offer nutritional substitutes to meet R45's dietary needs. This placed the resident at risk for malnutrition, complications from allergic reactions, and further dietary concerns. Findings Include: -The electronic medical record (EMR) documented the following diagnosis for R45: [...]
Inspectors wroteThe facility identified at census of 66 resident. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to ensure that a communication process was implemented, which included how the communication was documented, between the facility and the hospice (type of health care that focuses on a terminally ill patient's pain and symptoms and attends to their emotional and spiritual needs at the end of life) provider, and a failed to provide a description of the services, medication, and equipment provided by hospice to Resident (R)16 and R48. This deficient practice created a risk for missed opportunities for hospice services, miscommunication between hospice and facility, and delayed treatment.
37 fire safety citations on file: 5 on April 16, 2025, 11 on August 9, 2023, 21 on December 30, 2021.
| Date | Penalty | Amount or length |
|---|---|---|
| January 23, 2025 | Fine | $17,345 |
| September 17, 2024 | Fine | $10,036 |
| August 19, 2024 | Fine | $10,036 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Kansas | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.99 | 4.07 | 3.86 |
| Registered nurses | 0.78 | 0.71 | 0.69 |
| All nursing staff on weekends | 3.50 | 3.60 | 3.42 |
| Nurse aides | 2.29 | ||
| Licensed practical nurses | 0.92 | ||
| Nursing staff turnover (share who left in a year) | not reported | 48.1% | 45.8% |
| Registered nurse turnover | not reported | 42.0% | 42.9% |
| Administrators who left | not reported |
CMS expects 4.00 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.18 on weekdays and 3.50 on weekends, 16% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 6.2% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.02 in April to June 2025 to 3.99 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.99 | 0.78 | 4.18 | 3.50 | 6.2% | 0 of 90 | 55 |
| Jul to Sep 2025 | 3.90 | 0.68 | 4.11 | 3.34 | 4.7% | 1 of 92 | 59 |
| Apr to Jun 2025 | 4.02 | 0.65 | 4.24 | 3.45 | 12.0% | 0 of 91 | 61 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Kansas, Jan to Mar 2026 | 4.01 | 0.67 | 4.19 | 3.56 | 4.8% | 0.6% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Kansas, all employers | |||
| CNAs (nursing assistants) | $18.27 | $17.41 to $21.24 | 24,610 |
| LPNs and LVNs | $29.69 | $27.05 to $33.40 | 7,530 |
| Registered nurses | $38.14 | $35.24 to $45.53 | 33,800 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Kansas | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 11.1 | 17.9 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.4 | 1.6 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.2 | 2.9 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 3.0 | 4.3 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.3 | 1.9 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 13.3 | 16.2 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 4.9 | 4.4 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 16.8 | 18.1 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 16.0 | 22.4 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 6.5 | 11.5 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.2 | 1.8 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.1 | 2.1 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for The Healthcare Resort of Olathe's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (62.3% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
62.3% this home
Better than the national rate
US median of homes 51.5% · Kansas: 42 better, 17 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 222 eligible stays.
10.4% this home
No different from the national rate
US median of homes 10.7% · Kansas: 3 better, 0 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 238 eligible stays.
8.4% this home
No different from the national rate
US median of homes 7.1% · Kansas: 3 better, 0 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 124 eligible stays.
67.9% this home
Median of homes: Kansas55.7% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 81 residents counted.
2.3% this home
Median of homes: Kansas0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 131 residents counted.
2.8% this home
Median of homes: Kansas2.1% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 131 residents counted.
100.0% this home
Median of homes: Kansas99.3% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 69 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: TWO TRAILS HEALTHCARE INC. CMS links this home to The Ensign Group, a group of 344 nursing homes averaging 3.2 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Gateway Healthcare LLC | Direct ownership interest | Organization | 01/28/2014 | |
| The Ensign Group Inc | Indirect ownership interest | Organization | 01/28/2014 | |
| Allen, Martha | Managing control - governing body | Individual | 04/01/2025 | |
| Reese, Robert | Managing control - governing body | Individual | 11/01/2015 | |
| Burnam, Soon | Corporate officer | Individual | 01/28/2014 | |
| Jorgensen, David | Corporate officer | Individual | 01/01/2024 | |
| Keetch, Chad | Corporate officer | Individual | 03/01/2011 | |
| Lewis, Corwin | Corporate officer | Individual | 01/01/2019 | |
| Sato, Ami | Corporate officer | Individual | 09/09/2024 | |
| Allen, Martha | Operational/managerial control | Individual | 04/01/2025 | |
| Reese, Robert | Operational/managerial control | Individual | 11/01/2015 | |
| Port, Barry | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 06/16/2025 | |
| Ensign Services Inc | Adp of the SNF | Organization | 01/28/2014 | |
| Welltower Op, LLC | Adp of the SNF | Organization | 01/29/2014 | |
| Allen, Martha | Adp of the SNF | Individual | 06/17/2025 | |
| Reese, Robert | Adp of the SNF | Individual | 06/17/2025 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.