Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Shawnee Post Acute Rehabilitation Center during CMS and state inspections, most recent first.
Failure to change gloves and perform hand hygiene after personal care: A CNA assisted two residents with toileting and incontinence care, then continued touching resident belongings and providing additional care with the same soiled gloves. The CNA handled a toothbrush, applied toothpaste, brushed a resident’s hair, wiped a resident’s mouth, and later acknowledged she had not removed her gloves after personal care and did not wash her hands.
Failure to protect resident dignity and privacy during care and in common areas. A resident was observed in the dining room with an uncovered urinary collection bag visible to others, and an AN stated nasal spray should not be given at the dining room table but in a private area. The AN verified the catheter bag should be covered and urine should not be visible.
A resident with schizoaffective disorder missed an ordered Invega Sustenna dose, and the chart lacked a nursing note or rationale for the omission. Another resident with Alzheimer’s disease and other psychiatric diagnoses remained on Seroquel without documented physician rationale, unsuccessful nonpharmacologic attempts, or a risk-versus-benefit review. Staff interviews confirmed the first resident’s refusal process was expected to be documented and that the second resident had no behaviors and stayed in her room most of the time.
Failure to Provide Bed Hold Notices and Ombudsman Notifications: The facility failed to provide written bed hold information and failed to notify the LTCO when two residents were transferred to the hospital. One resident's record lacked a bed hold policy, a resident or representative signature, and evidence of LTCO notification after transfer for wound surgery. Another resident had hospital transfers for SOB and pneumonia, but the record lacked bed hold notification for the family/representative and lacked evidence of LTCO notification for either transfer.
A resident with dementia-related cognitive impairment and a documented Farsi language barrier did not have staff consistently using alternative communication methods. The care plan directed staff to use a translator service or family translation, but a CNA stated she did not know what the resident said and did not know other ways to communicate. An LN and an Administrative Nurse said the facility relied on interpreter service or family translation, and the facility did not provide a communication policy when requested.
Failure to provide ordered foam dressings for a resident with severely contracted hands. A resident with contractures, hemiparesis/hemiplegia, and severe cognitive impairment had a care plan and MD order for Hydrofera blue foam or other foam dressing in both palms and under the nails daily or as tolerated for skin integrity. OT noted skin breakdown on the palms and severe hand contractures, but surveyors observed the resident sitting in a Broda chair with no foam supports in place. An LPN could not explain why the foam was absent, and an admin nurse stated the foam should be placed in both hands daily.
Failure to follow transfer safety interventions: A resident with dementia, repeated falls, muscle weakness, and unsteadiness on her feet was identified as a medium fall risk and had care plan directions for care in pairs and use of a gait belt during all transfers. After a transfer from a wheelchair to bed, the resident's knees buckled and she was lowered to the floor, resulting in a skin tear. Survey observation later showed a CNA transferring the resident without a gait belt and without awareness that two staff were required.
Failure to document appropriate indication for antipsychotic use: A resident with dementia-related diagnoses and daily Seroquel use had no documented physician rationale in the EMR showing unsuccessful nonpharmacological interventions or a risk-versus-benefit review for continued use. The CP noted the diagnosis was not a CMS-approved indication and requested supporting documentation, but the physician directed staff to the progress notes instead; nursing staff reported the resident rarely left the room, did not have behaviors, and stayed in the room most of the time.
Medication storage and labeling were not maintained as required. An opened vial of tuberculin in a med room refrigerator had no open date on the label, and a stock bottle of Vitamin B12 on a med cart was expired. A LN stated the tuberculin should have been dated when opened, and an Administrative Nurse confirmed expired meds were to be removed from stock or disposed of.
Failure to Change Gloves and Perform Hand Hygiene After Personal Care
Penalty
Summary
The facility failed to ensure staff performed appropriate glove changing and hand hygiene during personal care for two residents, R18 and R52. On 02/17/26 at 07:40 AM, CNA M assisted R18 with toileting and incontinence care, donned clean gloves, removed and discarded the resident’s incontinence brief, and then continued care with the same soiled gloves by pulling up the brief and pants. CNA M then transferred R18 back to the wheelchair, pushed her to the sink, picked up the resident’s toothbrush, applied toothpaste, handed it to her, brushed her hair, wiped her mouth with a wet paper towel, bagged trash, and only then removed the gloves and pushed the resident to the dining room. When interviewed, CNA M verified she had not removed her gloves after providing personal care and stated she should have.
Failure to Protect Resident Dignity and Privacy
Penalty
Summary
The facility failed to treat residents with respect, dignity, and privacy during care and while residents were in common areas. On 02/17/26 at 12:10 PM, observation showed R8 propelling through the dining room with a urinary collection bag positioned between his legs in the wheelchair, without a dignity cover, and the bag was half full of yellow urine and visible to others. On 02/18/26 at 08:40 AM, the Administrative Nurse stated staff should not administer nasal spray at the dining room table and should take the resident to her room or another private area. The Administrative Nurse also verified that the catheter bag should be covered and urine should not be visible. The facility’s Resident Rights policy stated that each resident would be treated with kindness, dignity, and respect, including privacy in treatment and in the care of personal needs.
Unnecessary Psychotropic Medication Use and Missed Antipsychotic Administration
Penalty
Summary
The facility failed to follow physician orders for an antipsychotic medication for one resident with schizoaffective disorder, bipolar type, altered mental status, and need for continuous supervision. The resident’s record showed an order for Invega Sustenna 234 mg IM every 28 days, but the February 2026 MAR documented the medication was not administered as ordered on 02/10/26, and the record contained no nursing note or rationale explaining why it was missed. The resident’s chart also showed the medication had been refused on a prior date, yet the facility documented that the medication was later administered by the nurse practitioner on that date. The facility also failed to ensure appropriate indication and documentation for continued antipsychotic use for another resident with Alzheimer’s disease, delusional misidentification syndrome, anxiety, and major depressive disorder. That resident’s MDS documented severe cognitive impairment, dependence for all ADLs, and daily antipsychotic use. The care plan included medication administration, monitoring for side effects and effectiveness, non-pharmacological interventions, and consultation with pharmacy and the physician for dosage reduction when clinically indicated, but the record lacked evidence of a documented physician rationale that included unsuccessful attempts at nonpharmacological symptom management and a risk-versus-benefit review for ongoing Seroquel use. During interviews, staff stated the resident who refused medication would have the medication reoffered and the physician notified, with documentation in the nursing notes, but the chart lacked documentation showing that occurred for the missed dose. For the resident receiving Seroquel, staff stated she rarely left her room, did not have behaviors, did not attend activities, and stayed in her room most of the time. Administrative nursing staff were unable to provide a risk-versus-benefit explanation or indication for the continued Seroquel use.
Failure to Provide Bed Hold Notices and Ombudsman Notifications
Penalty
Summary
The facility failed to notify the Office of the Long-Term Care Ombudsman and failed to provide written bed hold information when two residents were transferred to the hospital. For one resident, the record documented admission to an acute care hospital for wound surgery and later return to the facility on a stretcher by medical transport, but the clinical record lacked a bed hold policy, a resident or representative signature, and documentation that the LTCO was notified of the discharge to the hospital. Social Service Designee X verified the facility could not provide written evidence of a bed hold policy for this resident and stated residents should have the resident or family sign the facility bed hold policy when discharged. For another resident, the record documented two hospital admissions, one for shortness of air and another for pneumonia. The clinical record lacked evidence that the resident's family or representative received bed hold notification for the second transfer and lacked evidence that the Ombudsman was notified for either hospital transfer. Social Service X verified the facility could not provide written evidence of a bed-hold policy or ombudsman notification for the resident's hospital transfers, and Administrative Nurse D stated she was unaware the resident lacked a bed hold notification for the later transfer and that the ombudsman should be notified monthly of hospital transfers.
Failure to Use Alternative Communication Methods for a Farsi-Speaking Resident
Penalty
Summary
The facility failed to ensure staff used alternative communication methods for a resident who spoke Farsi and had a documented language barrier. The resident’s EMR listed senile degeneration of the brain, anxiety, and major depressive disorder, and the quarterly MDS documented long- and short-term memory problems, severely impaired decision-making skills, and need for partial staff assistance with dressing, showers, toileting hygiene, mobility, and transfers. The care plan stated the resident spoke Farsi, could communicate with a translator, preferred her daughter or family to translate, and that staff should anticipate and meet her needs and provide a translator as necessary. During observation, a CNA told the resident she would help her get up to go to the bathroom, but when asked what the resident said, the CNA stated she did not know and did not know of any other ways to communicate with the resident. A LN stated the facility used an interpreter service or family if they had difficulty understanding the resident, and an Administrative Nurse stated the family preferred staff call them to translate if staff did not know what the resident wanted or needed, adding that it was easier than calling the translator service. The facility did not provide a communication policy when requested.
Failure to Provide Ordered Foam Dressings for Contractured Hands
Penalty
Summary
The facility failed to ensure staff provided the physician-ordered foam dressings to protect Resident 3’s bilateral hand contractures. Resident 3 had diagnoses of contractures of both hands and hemiparesis/hemiplegia, with severely impaired cognition, dependence on staff for all ADLs, and use of a Broda chair and Hoyer lift. Her care plan and physician order directed staff to place Hydrofera blue foam or other available foam dressing in both palms and under the nails daily or as tolerated for skin integrity in the setting of severely contracted hands. OT documentation noted new skin breakdown on the bilateral palms and severely contracted hands, and that the resident had previously been resistive to palm protectors and orthotics but would allow foam to be reapplied. During observations on 02/16/26 and 02/17/26, Resident 3 was seen sitting in her Broda chair with her bilateral hands and fingers tightly closed and no foam support noted in her palms or under her fingers. A licensed nurse stated the resident should have foam in her hands but could not say why it was not present, and an administrative nurse stated she expected the foam to be placed in both hands daily and in the palms each morning for the resident’s contracted fingers. The facility’s contracture documentation policy required residents with contractures to receive appropriate treatment and services based on comprehensive assessment, with a physician’s order for ROM programs and recommended splints, braces, or assistive devices.
Failure to Follow Transfer Safety Interventions
Penalty
Summary
The facility failed to provide a safe environment for a resident who had diagnoses of dementia, repeated falls, muscle weakness, and unsteadiness on her feet, and whose fall risk assessment identified her as a medium fall risk. Her care plan directed staff to provide a safe environment, remind her to call for assistance with transfers, care in pairs, ensure nonskid footwear, and use a gait belt during all transfers. Despite these interventions, the resident sustained a fall during a transfer from a wheelchair to bed when her knees buckled and the caregiver lowered her to the floor, after which a skin tear was found on her right elbow. Survey observation also showed a CNA transferring the resident from her wheelchair to the toilet and back without using a gait belt and without awareness that two staff were required for her care. The CNA assisted the resident with toileting, incontinence care, dressing, handwashing, and transfer back to the wheelchair while using only one hand support under the resident's arm. A nurse stated staff were to always use a gait belt for the resident's transfers, and an administrative nurse stated staff were to follow the care plan and care in pairs for the resident.
Failure to Document Appropriate Indication for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that the physician responded to the Consultant Pharmacist’s recommendation regarding Resident 78’s Seroquel use and whether it had an appropriate CMS indication. Resident 78 had diagnoses of Alzheimer’s disease, delusional misidentification syndrome, anxiety, and major depressive disorder, and the MDS documented long- and short-term memory problems, severely impaired decision-making, dependence on staff for all ADLs, and daily antipsychotic use. The care plan included medication administration, monitoring for side effects and effectiveness, consultation with pharmacy and the physician for dosage reduction when clinically indicated, non-pharmacological interventions, and monitoring for psychotic behavior as evidenced by agitation. The physician order initially directed Seroquel 25 mg by mouth at supper for anxiety and was later changed to Seroquel 25 mg, 0.5 mg by mouth in the evening for delusional misidentification syndrome. The EMR lacked documented physician rationale, including unsuccessful attempts at nonpharmacological symptom management and risk-versus-benefit information for continued Seroquel use. The Consultant Pharmacist documented that the diagnosis for quetiapine was not one of the CMS approved indications and requested a risk-versus-benefit statement, what had been tried and failed, and other nonpharmacological options used; the physician responded only that the requester should look in the resident’s progress notes. Subsequent monthly medication regimen reviews did not include further recommendations about the diagnosis for Seroquel use, and nursing staff stated the resident rarely left her room, did not have behaviors, did not attend activities, and stayed in her room most of the time.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure an opened vial of tuberculin in the medication room was dated when opened. During an observation of the Bend-1 hall medication room, the medication refrigerator contained an opened vial of tuberculin with an expiration date of 11/28, but no open date was written on the label. A LN stated she was not sure when the vial had been opened and said it should have an open date written on the label; she also stated she would discard the vial of tuberculin. The facility also failed to ensure stock medication on a medication cart was not expired. During an observation of the 2 Cart A medication cart, a CMA obtained medication to administer to residents and the cart was found to contain one bottle of Vitamin B12 500 mcg, 100 tablets that had expired in 12/2025. An Administrative Nurse verified that staff were to remove from stock or dispose of expired medications. The facility’s Medication Labels and Storage policy stated floor stock medications are to be kept in the original manufacturer’s container with the expiration date and lot number clearly evident, and the date the medication was opened is to be placed on the container.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 854 citations issued within 25 miles in the last 12 months — including the 23 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Overland Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garden Terrace At Overland Park | 1.1 mi | ★★★★★ | 4 | 2 |
| Aspen Health And Wellness | 1.4 mi | ★★★★★ | 4 | 0 |
| Merriam Gardens Healthcare & Rehabilitation Center | 2 mi | ★★★★★ | 0 | 0 |
| Shawnee Gardens Healthcare & Rehab Center | 2.4 mi | ★★★★★ | 2 | 0 |
| Sharon Lane Health And Rehabilitation | 2.4 mi | ★★★★★ | 17 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Shawnee Post Acute Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.