Cycle 1
Health 2024-12-11 · Fire 2024-12-11
2 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Overbrook, KS
Brookside Retirement Community
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
700 W 7th Street, Overbrook, KS
(785) 665-7124
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
49
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1985-03-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.45
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.57
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.50
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.52
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.02
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.15
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.84
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,228
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
58.67
Composite VBP score used to determine payment impact.
Payment multiplier
1.0139
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.58
Baseline 17.54% · Performance 18.85% · Measure score 5.58 · Achievement 5.58 · Improvement 0
Healthcare-associated infections
4.79
Baseline 5.58% · Performance 6.40% · Measure score 4.79 · Achievement 4.79 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
7.23
Baseline 4.98 hours · Performance 5.14 hours · Measure score 7.23 · Achievement 7.23 · Improvement 1.41
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.21% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 80 · Observed rate 10% · Lower 95% interval 7.48% |
| Discharge to community | 61.61% |
50.57%
11 pts better
|
Better than the National Rate · Eligible stays 67 · Observed rate 64.18% · Lower 95% interval 52.49% |
| Medicare spending per beneficiary | 0.61 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 9.52% |
95.27%
85.8 pts worse
|
Numerator 4 · Denominator 42 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 42 |
| Discharge self-care score | 63.89% |
53.69%
10.2 pts better
|
Numerator 23 · Denominator 36 |
| Discharge mobility score | 69.44% |
50.94%
18.5 pts better
|
Numerator 25 · Denominator 36 |
| Pressure ulcers or injuries, new or worsened | 4.76% |
2.29%
2.5 pts worse
|
Numerator 2 · Denominator 42 · Adjusted rate 5.92% |
| Healthcare-associated infections requiring hospitalization | 6.4% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 2.27% · Lower 95% interval 3.04% |
| Staff COVID-19 vaccination coverage | 3.3% |
8.2%
4.9 pts worse
|
Numerator 3 · Denominator 91 |
| Staff flu vaccination coverage | 11.02% |
42%
31 pts worse
|
Numerator 13 · Denominator 118 |
| Discharge function score | 63.89% |
56.45%
7.4 pts better
|
Numerator 23 · Denominator 36 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 34.78% |
96.28%
61.5 pts worse
|
Numerator 8 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.8
0.8 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.7 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.1 |
2.2
2.1 pts better
|
1.8
1.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.1 · Observed 0.1 · Expected 1.4 · Used in QM five-star |
| 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 | 93.6% |
95.5%
1.9 pts worse
|
95.5%
1.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
4.4%
3.3 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 34.3% |
5.6%
28.7 pts worse
|
11.4%
22.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 39.5% · Q3 37.8% · Q4 35.6% · 4Q avg 34.3% |
| Percentage of long-stay residents who lose too much weight | 10.8% |
5.0%
5.8 pts worse
|
5.4%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 5.4% · Q3 15.8% · Q4 14.7% · 4Q avg 10.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.7% |
23.2%
8.5 pts better
|
19.6%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 16.2% · Q3 13.2% · Q4 16.7% · 4Q avg 14.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.5% |
19.8%
1.3 pts better
|
16.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 18.2% · Q3 20.0% · Q4 18.8% · 4Q avg 18.5% · 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 | 19.0% |
18.4%
0.6 pts worse
|
16.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 23.0% · Q3 20.9% · Q4 19.5% · 4Q avg 19.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.3% |
18.8%
2.5 pts worse
|
14.9%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 16.2% · Q3 34.2% · Q4 33.3% · 4Q avg 21.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.8%
1.4 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.7% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 7.8% |
3.1%
4.7 pts worse
|
1.7%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 8.5% · Q3 8.5% · Q4 4.7% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.5% |
23.2%
5.7 pts better
|
19.8%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 22.9% · Q3 22.5% · Q4 12.8% · 4Q avg 17.5% |
| Percentage of long-stay residents with pressure ulcers | 1.3% |
4.6%
3.3 pts better
|
5.1%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 3.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.0% |
75.6%
19.4 pts better
|
81.7%
13.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 91.7% · Q3 92.6% · Q4 96.2% · 4Q avg 95.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
11.7%
11.7 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
2.2%
0.9 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.3% |
73.5%
20.8 pts better
|
79.7%
14.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.8% |
23.0%
5.2 pts better
|
23.9%
6.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.8% · Observed 14.7% · Expected 19.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-04 · Fire 2023-01-04
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2021-05-18 · Fire 2021-05-18
0 health deficiencies
No concentrated health issue counts in this cycle.
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-11
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2025-02-03
F · Potential for more than minimal harm
2024-12-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-03
F · Potential for more than minimal harm
2024-12-11
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-02-03
F · Potential for more than minimal harm
2024-12-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-03
F · Potential for more than minimal harm
2024-12-11
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2025-02-03
E · Potential for more than minimal harm
2024-12-11
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-02-03
E · Potential for more than minimal harm
2024-12-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-03
F · Potential for more than minimal harm
2023-01-04
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-11-18
F · Potential for more than minimal harm
2023-01-04
K321 · Smoke Deficiencies
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 2022-11-18
F · Potential for more than minimal harm
2023-01-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-11-18
F · Potential for more than minimal harm
2023-01-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-18
F · Potential for more than minimal harm
2023-01-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-18
F · Potential for more than minimal harm
2023-01-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-18
F · Potential for more than minimal harm
2023-01-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-11-18
E · Potential for more than minimal harm
2023-01-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-11-18
D · Potential for more than minimal harm
2023-01-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-11-18
F · Potential for more than minimal harm
2021-05-18
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.
Corrected 2021-08-06
F · Potential for more than minimal harm
2021-05-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-07-07
F · Potential for more than minimal harm
2021-05-18
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2021-08-06
F · Potential for more than minimal harm
2021-05-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-07-07
F · Potential for more than minimal harm
2021-05-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-08-06
F · Potential for more than minimal harm
2021-05-18
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2021-08-06
F · Potential for more than minimal harm
2021-05-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-08-06
F · Potential for more than minimal harm
2021-05-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-08-06
E · Potential for more than minimal harm
2021-05-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-08-06
E · Potential for more than minimal harm
2021-05-18
K321 · Smoke Deficiencies
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 2021-08-06
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-12-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-12-11
F625 · Resident Rights Deficiencies
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 2024-12-23
D · Potential for more than minimal harm
2023-01-04
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-01-16
D · Potential for more than minimal harm
2023-01-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-16
D · Potential for more than minimal harm
2023-01-04
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 2023-01-16
D · Potential for more than minimal harm
2023-01-04
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-01-16
Penalties and ownership
What sits behind the stars
Ownership
Averill, Susan
5% Or Greater Indirect Ownership Interest · Individual
Alegria Living & Healthcare, Inc.
5% Or Greater Direct Ownership Interest · Organization
Averill, Nathan
Operational/Managerial Control · Individual
Averill, Nathan
Contracted Managing Employee · Individual
Averill, Scott
5% Or Greater Direct Ownership Interest · Individual
Averill, Scott
Operational/Managerial Control · Individual
Averill, Scott
Corporate Officer · Individual
Averill, Scott
Contracted Managing Employee · Individual
Averill, Susan
Operational/Managerial Control · Individual
Averill, Susan
Corporate Officer · Individual
Averill, Susan
Contracted Managing Employee · Individual
Conklin, Tammy
Operational/Managerial Control · Individual
Conklin, Tammy
W-2 Managing Employee · Individual
Davidson, Sharrell
Operational/Managerial Control · Individual
Davidson, Sharrell
W-2 Managing Employee · Individual
Hoback, Denise
Operational/Managerial Control · Individual
Hoback, Denise
Corporate Officer · Individual
Hoback, Denise
Contracted Managing Employee · Individual
Jones, Ciara
Operational/Managerial Control · Individual
Jones, Ciara
W-2 Managing Employee · Individual
Jones, Tracy
Operational/Managerial Control · Individual
Jones, Tracy
W-2 Managing Employee · Individual
Joya Living & Healthcare Inc
Operational/Managerial Control · Organization
Wessel, Peggy
Operational/Managerial Control · Individual
Wessel, Peggy
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Mccrite Plaza Health Center
Topeka, KS
5-star overall rating with 4-star inspections with $9,113 in total fines with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Osage Nursing & Rehabilitation Center
Osage City, KS
1-star overall rating with 1-star inspections with $14,891 in total fines with 12 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
#3
Brewster Health Center
Topeka, KS
5-star overall rating with 4-star inspections with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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