5 health deficiencies
Top issue: Infection Control (1 deficiency)
10 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Shawnee, KS
5-star overall rating with 3-star inspections with 5 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
12802 Johnson Drive, Shawnee, KS
(913) 962-7600
Overall
5 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
92
Certified beds
Average residents
71
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Brookdale Senior Living
Operator or chain grouping
Approved since
2004-06-30
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
RN hours / resident day
1.44
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
1.91
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.16
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
2.25
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.89
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
1.29
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.51
CMS adjusted RN staffing hours
Adjusted total hours
4.39
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
7,359
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.95
Composite VBP score used to determine payment impact.
Payment multiplier
0.9857
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 17.49% · Performance 21.63% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
6.60
Baseline 3.95% · Performance 5.86% · Measure score 6.60 · Achievement 6.60 · Improvement 0
Total nurse turnover
1.40
Baseline 56.96% · Performance 57.94% · Measure score 1.40 · Achievement 1.40 · Improvement 0
Adjusted total nurse staffing
3.97
Baseline 3.45 hours · Performance 4.21 hours · Measure score 3.97 · Achievement 3.97 · Improvement 2.75
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.86% |
10.72%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 454 · Observed rate 14.54% · Lower 95% interval 9.99% |
| Discharge to community | 65.08% |
50.57%
14.5 pts better
|
Better than the National Rate · Eligible stays 459 · Observed rate 59.48% · Lower 95% interval 59.05% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 41.18% |
95.27%
54.1 pts worse
|
Numerator 84 · Denominator 204 |
| Falls with major injury | 0.49% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 204 |
| Discharge self-care score | 72.79% |
53.69%
19.1 pts better
|
Numerator 107 · Denominator 147 |
| Discharge mobility score | 47.62% |
50.94%
3.3 pts worse
|
Numerator 70 · Denominator 147 |
| Pressure ulcers or injuries, new or worsened | 3.92% |
2.29%
1.6 pts worse
|
Numerator 8 · Denominator 204 · Adjusted rate 4.7% |
| Healthcare-associated infections requiring hospitalization | 5.86% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 223 · Observed rate 4.93% · Lower 95% interval 3.64% |
| Staff COVID-19 vaccination coverage | 3.72% |
8.2%
4.5 pts worse
|
Numerator 7 · Denominator 188 |
| Staff flu vaccination coverage | 14.29% |
42%
27.7 pts worse
|
Numerator 27 · Denominator 189 |
| Discharge function score | 62.59% |
56.45%
6.1 pts better
|
Numerator 92 · Denominator 147 |
| Transfer of health information to provider | 95.83% |
95.95%
0.1 pts worse
|
Numerator 46 · Denominator 48 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 136 · Denominator 136 |
| Resident COVID-19 vaccinations up to date | 24.73% |
25.2%
0.5 pts worse
|
Numerator 23 · Denominator 93 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.8
0.4 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.3 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
2.2
1.2 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
91.8%
7.6 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.6% · 4Q avg 99.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.8% |
95.5%
2.3 pts better
|
95.5%
2.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.8% |
4.4%
2.4 pts worse
|
3.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 7.5% · Q3 9.8% · Q4 2.4% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.6% |
5.6%
3 pts better
|
11.4%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.6% · Q3 2.6% · Q4 2.5% · 4Q avg 2.6% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
5.0%
2 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 2.9% · Q4 5.6% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.6% |
23.2%
5.6 pts better
|
19.6%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 15.2% · Q3 17.1% · Q4 16.2% · 4Q avg 17.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.4% |
19.8%
9.4 pts better
|
16.7%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 10.7% · Q3 16.7% · Q4 3.0% · 4Q avg 10.4% · 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 ability to walk independently worsened | 10.2% |
18.4%
8.2 pts better
|
16.3%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.5% |
18.8%
5.3 pts better
|
14.9%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 15.6% · Q3 17.1% · Q4 8.6% · 4Q avg 13.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.8%
1.8 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.1% |
3.1%
2 pts worse
|
1.7%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 7.5% · Q3 4.9% · Q4 0.0% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.4% |
23.2%
1.8 pts better
|
19.8%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 26.6% · Q3 25.2% · Q4 24.1% · 4Q avg 21.4% |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
4.6%
2.9 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 7.4% · Q3 7.8% · Q4 7.5% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
75.6%
23.1 pts better
|
81.7%
17 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.2% · Q2 99.1% · Q3 98.0% · Q4 98.3% · 4Q avg 98.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
11.7%
4.3 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 6.8% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
2.2%
1.9 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.0% · Q3 0.0% · Q4 0.7% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.9% |
73.5%
24.4 pts better
|
79.7%
18.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.5% |
23.0%
3.5 pts better
|
23.9%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.5% · Observed 19.0% · Expected 23.2% · Used in QM five-star |
Survey summary
Top issue: Infection Control (1 deficiency)
10 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Top issue: Quality of Life and Care (7 deficiencies)
12 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
7 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
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.
Corrected 2026-02-23
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-23
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-02-23
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2026-02-23
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-02-23
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2026-02-23
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2026-02-23
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2026-02-23
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-02-23
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2026-02-23
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2024-03-12
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-03-12
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-12
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-12
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-12
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-01-31
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-02-15
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-06
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-01-30
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-12
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-12
Fire Safety
Use approved construction type or materials.
Corrected 2024-03-12
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-03-24
Fire Safety
Use approved construction type or materials.
Corrected 2022-03-24
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-03-24
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-03-24
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-03-24
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-03-24
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-03-24
Inspection history
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-16
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2026-01-16
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-01-16
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2026-01-16
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2026-01-16
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-08
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 2024-03-08
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-01-26
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-26
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-26
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-01-26
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-01-26
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-01-26
Health
Provide activities to meet all resident's needs.
Corrected 2024-01-26
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-01-26
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-01-26
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-01-26
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-01-26
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-01-26
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-01-26
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-01-26
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-26
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-26
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 2024-01-26
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 2024-01-26
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-01-26
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 2024-01-26
Health
Keep complete, dated laboratory records in the resident's record.
Corrected 2024-01-26
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-01-26
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-01-26
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-03-17
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-03-17
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2022-03-17
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-03-17
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-03-17
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-03-17
Penalties and ownership
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Security Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Nearby options
Shawnee, KS
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
Merriam, KS
1-star overall rating with 1-star inspections with $74,562 in total fines with 22 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
Shawnee, KS
1-star overall rating with 1-star inspections with abuse icon flag with $94,968 in total fines with 24 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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