Cycle 1
Health 2026-01-22 · Fire 2026-01-22
3 health deficiencies
Top issue: Administration (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Overland Park, KS
Brookdale Overland Park
4-star overall rating with 4-star inspections with $7,446 in total fines with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
12000 Lamar Avenue, Overland Park, KS
(913) 663-2888
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
94
Certified beds
Average residents
76
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Brookdale Senior Living
Operator or chain grouping
Approved since
2010-06-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.88
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
1.41
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.06
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.65
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.63
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.68
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.89
CMS adjusted RN staffing hours
Adjusted total hours
3.10
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,776
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.81
Composite VBP score used to determine payment impact.
Payment multiplier
0.9852
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.12
Baseline 22.84% · Performance 22.48% · Measure score 0.12 · Achievement 0 · Improvement 0.12
Healthcare-associated infections
5.45
Baseline 5.33% · Performance 6.21% · Measure score 5.45 · Achievement 5.45 · Improvement 0
Total nurse turnover
1.83
Baseline 58.77% · Performance 56.19% · Measure score 1.83 · Achievement 1.83 · Improvement 0.26
Adjusted total nurse staffing
4.11
Baseline 4.25 hours · Performance 4.25 hours · Measure score 4.11 · Achievement 4.11 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.63% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 695 · Observed rate 8.2% · Lower 95% interval 7.69% |
| Discharge to community | 68.96% |
50.57%
18.4 pts better
|
Better than the National Rate · Eligible stays 669 · Observed rate 64.28% · Lower 95% interval 64.66% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 95.91% |
95.27%
0.6 pts better
|
Numerator 375 · Denominator 391 |
| Falls with major injury | 0.51% |
0.77%
0.3 pts better
|
Numerator 2 · Denominator 391 |
| Discharge self-care score | 60.93% |
53.69%
7.2 pts better
|
Numerator 184 · Denominator 302 |
| Discharge mobility score | 62.91% |
50.94%
12 pts better
|
Numerator 190 · Denominator 302 |
| Pressure ulcers or injuries, new or worsened | 0.77% |
2.29%
1.5 pts better
|
Numerator 3 · Denominator 391 · Adjusted rate 0.75% |
| Healthcare-associated infections requiring hospitalization | 6.2% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 400 · Observed rate 5% · Lower 95% interval 4.27% |
| Staff COVID-19 vaccination coverage | 18.03% |
8.2%
9.8 pts better
|
Numerator 42 · Denominator 233 |
| Staff flu vaccination coverage | 25.62% |
42%
16.4 pts worse
|
Numerator 83 · Denominator 324 |
| Discharge function score | 70.86% |
56.45%
14.4 pts better
|
Numerator 214 · Denominator 302 |
| Transfer of health information to provider | 95.93% |
95.95%
About the same
|
Numerator 165 · Denominator 172 |
| Transfer of health information to patient | 98.4% |
96.28%
2.1 pts better
|
Numerator 184 · Denominator 187 |
| Resident COVID-19 vaccinations up to date | 57.84% |
25.2%
32.6 pts better
|
Numerator 107 · Denominator 185 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.8%
8.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.5%
4.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
4.4%
0.4 pts better
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.9% · Q3 6.7% · Q4 3.1% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.6%
5.6 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
5.0%
1.6 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.3% · Q4 4.0% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.3% |
23.2%
4.1 pts worse
|
19.6%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 26.1% · Q4 32.0% · 4Q avg 27.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.3% |
19.8%
2.5 pts better
|
16.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 20.0% · Q4 15.0% · 4Q avg 17.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.3% |
18.8%
8.5 pts better
|
14.9%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 4.3% · Q4 8.0% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
1.8%
0.5 pts better
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
3.1%
0.7 pts better
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.9% · Q3 3.3% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.0% |
23.2%
4.8 pts worse
|
19.8%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.6% · Q2 23.3% · Q3 48.0% · Q4 19.2% · 4Q avg 28.0% |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
4.6%
2.7 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.5% · Q3 1.7% · Q4 2.2% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
75.6%
22.4 pts better
|
81.7%
16.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 98.2% · Q3 96.9% · Q4 97.7% · 4Q avg 98.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.5% |
11.7%
1.2 pts better
|
12.0%
1.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.5% · Observed 10.0% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
2.2%
1.2 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.8% · Q3 1.1% · Q4 0.8% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.8% |
73.5%
19.3 pts better
|
79.7%
13.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.4% |
23.0%
1.4 pts worse
|
23.9%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 21.2% · Expected 20.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-06 · Fire 2024-03-06
13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-09-08 · Fire 2022-09-08
7 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Not marked corrected
E · Potential for more than minimal harm
2026-01-22
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Not marked corrected
E · Potential for more than minimal harm
2026-01-22
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Not marked corrected
E · Potential for more than minimal harm
2026-01-22
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Not marked corrected
E · Potential for more than minimal harm
2026-01-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Not marked corrected
E · Potential for more than minimal harm
2026-01-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Not marked corrected
E · Potential for more than minimal harm
2026-01-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Not marked corrected
F · Potential for more than minimal harm
2024-03-06
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-05-02
F · Potential for more than minimal harm
2024-03-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-02
F · Potential for more than minimal harm
2024-03-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-31
F · Potential for more than minimal harm
2024-03-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-02
D · Potential for more than minimal harm
2024-03-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-02
F · Potential for more than minimal harm
2022-09-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-10
F · Potential for more than minimal harm
2022-09-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
D · Potential for more than minimal harm
2026-01-22
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Not marked corrected
D · Potential for more than minimal harm
2026-01-22
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Not marked corrected
E · Potential for more than minimal harm
2024-03-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-20
E · Potential for more than minimal harm
2024-03-06
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-04-20
D · Potential for more than minimal harm
2024-03-06
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-04-20
D · Potential for more than minimal harm
2024-03-06
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-04-20
D · Potential for more than minimal harm
2024-03-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-20
D · Potential for more than minimal harm
2024-03-06
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-20
D · Potential for more than minimal harm
2024-03-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-20
D · Potential for more than minimal harm
2024-03-06
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-04-20
D · Potential for more than minimal harm
2024-03-06
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-04-20
D · Potential for more than minimal harm
2024-03-06
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-04-20
D · Potential for more than minimal harm
2024-03-06
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-04-20
D · Potential for more than minimal harm
2024-03-06
F775 · Administration Deficiencies
Health
Keep complete, dated laboratory records in the resident's record.
Corrected 2024-04-20
D · Potential for more than minimal harm
2024-03-06
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-04-20
J · Immediate jeopardy
2023-06-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-01-30
E · Potential for more than minimal harm
2022-09-08
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-11-03
E · Potential for more than minimal harm
2022-09-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-03
D · Potential for more than minimal harm
2022-09-08
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-11-03
D · Potential for more than minimal harm
2022-09-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-11-03
D · Potential for more than minimal harm
2022-09-08
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-11-03
D · Potential for more than minimal harm
2022-09-08
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-11-03
Penalties and ownership
What sits behind the stars
$7,446
2023-06-15
Fine
Fine · fine $7,446
Fine
Ownership
Ally Bank
5% Or Greater Security Interest · Organization
Davison, Andralie
Operational/Managerial Control · Individual
Ellis, Kimberly
Operational/Managerial Control · Individual
Kussow, Dawn
Operational/Managerial Control · Individual
La Marre, Kevin
Operational/Managerial Control · Individual
Maher, Mary
Operational/Managerial Control · Individual
Munoz, Anna
Operational/Managerial Control · Individual
Stengle, Nikolas
Operational/Managerial Control · Individual
White, Chadwick
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Village Shalom Inc
Overland Park, KS
3-star overall rating with 2-star inspections with $16,153 in total fines with 15 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#2
Ignite Medical Resort Overland Park LLC
Overland Park, KS
1-star overall rating with 2-star inspections with $6,942 in total fines with 14 recent health deficiencies with 23 fire-safety deficiencies in the latest cycle
#3
Advanced Health Care Of Overland Park
Overland Park, KS
5-star overall rating with 3-star inspections with $13,397 in total fines with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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