Overland Park, KS

Colonial Village

2-star overall rating with 2-star inspections with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle

12500 W 137th St, Overland Park, KS

(913) 730-3700

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Pivotal Health Care

Operator or chain grouping

Approved since

2018-12-12

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

9 facilities

Chain averages 4 overall / 4 health / 4 staffing / 4 quality stars

Changed ownership

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

0.93

Registered nurse staffing · state 0.72 · national 0.68

LPN hours / resident day

0.63

Licensed practical nurse staffing · state 0.67 · national 0.87

Aide hours / resident day

2.74

Nurse aide staffing · state 2.69 · national 2.35

Total nurse hours

4.30

All reported nurse hours · state 4.07 · national 3.89

Licensed hours

1.56

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

3.83

Weekend nurse staffing · state 3.58 · national 3.43

Weekend RN hours

0.69

Weekend registered nurse coverage · state 0.50 · national 0.47

Physical therapist

0.07

Reported PT staffing · state 0.04 · national 0.07

Adjusted RN hours

1.04

CMS adjusted RN staffing hours

Adjusted total hours

4.82

CMS adjusted total nurse staffing hours

Case-mix index

1.22

Higher values indicate more complex resident acuity

RN turnover

57%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

63%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

7,391

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

29.89

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

How the VBP score is built

Readmission

1.18

Baseline 18.83% · Performance 20.89% · Measure score 1.18 · Achievement 1.18 · Improvement 0

Healthcare-associated infections

4.03

Baseline 7.45% · Performance 6.63% · Measure score 4.03 · Achievement 4.03 · Improvement 2.84

Total nurse turnover

1.82

Baseline 84.91% · Performance 70.97% · Measure score 1.82 · Achievement 0 · Improvement 1.82

Adjusted total nurse staffing

4.92

Baseline 5.19 hours · Performance 4.48 hours · Measure score 4.92 · Achievement 4.92 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.41%	10.72% 0.3 pts better	No Different than the National Rate · Eligible stays 113 · Observed rate 8.85% · Lower 95% interval 6.61%
Discharge to community	48.8%	50.57% 1.8 pts worse	No Different than the National Rate · Eligible stays 100 · Observed rate 45% · Lower 95% interval 38.73%
Medicare spending per beneficiary	0.82	1.02 0.2 pts better
Drug regimen review with follow-up	98.41%	95.27% 3.1 pts better	Numerator 62 · Denominator 63
Falls with major injury	1.59%	0.77% 0.8 pts worse	Numerator 1 · Denominator 63
Discharge self-care score	54.9%	53.69% 1.2 pts better	Numerator 28 · Denominator 51
Discharge mobility score	39.22%	50.94% 11.7 pts worse	Numerator 20 · Denominator 51
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 63 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.63%	7.12% 0.5 pts better	No Different than the National Rate · Eligible stays 63 · Observed rate 4.76% · Lower 95% interval 3.77%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 105
Staff flu vaccination coverage	3.96%	42% 38 pts worse	Numerator 4 · Denominator 101
Discharge function score	60.78%	56.45% 4.3 pts better	Numerator 31 · Denominator 51
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 40 · Denominator 40
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	48.48%	25.2% 23.3 pts better	Numerator 16 · Denominator 33

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.6	1.8 0.2 pts better	1.9 0.3 pts better	Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.1 · Expected 2.5 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.1	2.2 1.1 pts better	1.8 0.7 pts better	Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.4 · Expected 2.0 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.1%	91.8% 6.3 pts better	93.4% 4.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 91.7% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.1%
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	4.7%	4.4% 0.3 pts worse	3.3% 1.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 6.9% · Q3 3.7% · Q4 3.7% · 4Q avg 4.7% · 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	13.8%	5.0% 8.8 pts worse	5.4% 8.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q2 17.4% · Q3 17.4% · Q4 9.1% · 4Q avg 13.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	4.3%	23.2% 18.9 pts better	19.6% 15.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 8.7% · Q4 8.7% · 4Q avg 4.3%
Percentage of long-stay residents who received an antipsychotic medication	14.5%	19.8% 5.3 pts better	16.7% 2.2 pts better	Long Stay · 2024Q4-2025Q3 · Q3 19.0% · Q4 10.0% · 4Q avg 14.5% · 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	28.4%	18.4% 10 pts worse	16.3% 12.1 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 28.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	18.5%	18.8% 0.3 pts better	14.9% 3.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 24.0% · Q3 13.0% · Q4 8.7% · 4Q avg 18.5% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.8%	1.8% About the same	1.0% 0.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q2 4.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.0%	3.1% 1.1 pts better	1.7% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.4% · Q3 0.0% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	30.6%	23.2% 7.4 pts worse	19.8% 10.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q2 35.3% · Q3 41.5% · Q4 19.5% · 4Q avg 30.6%
Percentage of long-stay residents with pressure ulcers	4.6%	4.6% About the same	5.1% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 7.0% · Q3 3.4% · Q4 3.5% · 4Q avg 4.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	90.3%	75.6% 14.7 pts better	81.7% 8.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 87.3% · Q2 81.8% · Q3 94.0% · Q4 100.0% · 4Q avg 90.3%
Percentage of short-stay residents who had an outpatient emergency department visit	8.6%	11.7% 3.1 pts better	12.0% 3.4 pts better	Short Stay · 20240701-20250630 · Adjusted 8.6% · Observed 7.8% · Expected 10.2% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	3.1%	2.2% 0.9 pts worse	1.6% 1.5 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.4% · Q3 2.5% · Q4 5.9% · 4Q avg 3.1% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	92.7%	73.5% 19.2 pts better	79.7% 13 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 92.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	31.7%	23.0% 8.7 pts worse	23.9% 7.8 pts worse	Short Stay · 20240701-20250630 · Adjusted 31.7% · Observed 25.5% · Expected 19.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-10-31 · Fire 2024-10-31

10 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

7 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Cycle 2 Health 2023-06-08 · Fire 2023-06-08

14 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (6 deficiencies)

Cycle 3 Health 2021-11-02 · Fire 2021-11-02

4 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

8 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-10-31

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 2025-01-06

F · Potential for more than minimal harm 2024-10-31

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2025-01-06

F · Potential for more than minimal harm 2024-10-31

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-01-06

F · Potential for more than minimal harm 2024-10-31

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2025-01-06

F · Potential for more than minimal harm 2024-10-31

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-01-06

D · Potential for more than minimal harm 2024-10-31

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-01-06

D · Potential for more than minimal harm 2024-10-31

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-01-06

F · Potential for more than minimal harm 2023-06-08

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-07-28

F · Potential for more than minimal harm 2023-06-08

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2023-07-28

F · Potential for more than minimal harm 2023-06-08

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 2023-07-28

F · Potential for more than minimal harm 2023-06-08

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-07-28

E · Potential for more than minimal harm 2023-06-08

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2023-07-28

D · Potential for more than minimal harm 2023-06-08

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-07-28

D · Potential for more than minimal harm 2023-06-08

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-07-28

D · Potential for more than minimal harm 2023-06-08

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2023-07-28

D · Potential for more than minimal harm 2023-06-08

K753 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of highly flammable decorations.

Corrected 2023-07-28

F · Potential for more than minimal harm 2021-11-02

E24 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for volunteers.

Corrected 2022-01-07

F · Potential for more than minimal harm 2021-11-02

K131 · Construction Deficiencies

Fire Safety

Meet requirements for sections of health care facilities separated by fire resistive construction.

Corrected 2022-01-07

F · Potential for more than minimal harm 2021-11-02

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 2022-01-07

F · Potential for more than minimal harm 2021-11-02

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2022-01-07

F · Potential for more than minimal harm 2021-11-02

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-01-07

F · Potential for more than minimal harm 2021-11-02

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-01-07

F · Potential for more than minimal harm 2021-11-02

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2022-01-07

E · Potential for more than minimal harm 2021-11-02

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2022-01-07

Inspection history

Recent health citations

G · Actual harm 2024-10-31

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-11-21

F · Potential for more than minimal harm 2024-10-31

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2024-11-21

F · Potential for more than minimal harm 2024-10-31

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-11-21

E · Potential for more than minimal harm 2024-10-31

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-11-21

D · Potential for more than minimal harm 2024-10-31

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2024-11-21

D · Potential for more than minimal harm 2024-10-31

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 2024-11-21

D · Potential for more than minimal harm 2024-10-31

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-11-21

D · Potential for more than minimal harm 2024-10-31

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 2024-11-21

D · Potential for more than minimal harm 2024-10-31

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 2024-11-21

D · Potential for more than minimal harm 2024-10-31

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 2024-11-21

E · Potential for more than minimal harm 2023-06-08

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 2023-06-30

E · Potential for more than minimal harm 2023-06-08

F761 · Pharmacy Service Deficiencies

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 2023-06-30

E · Potential for more than minimal harm 2023-06-08

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-06-30

E · Potential for more than minimal harm 2023-06-08

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-06-30

D · Potential for more than minimal harm 2023-06-08

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2023-06-30

D · Potential for more than minimal harm 2023-06-08

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2023-06-30

D · Potential for more than minimal harm 2023-06-08

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2023-06-30

D · Potential for more than minimal harm 2023-06-08

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2023-06-30

D · Potential for more than minimal harm 2023-06-08

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 2023-06-30

D · Potential for more than minimal harm 2023-06-08

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2023-06-30

D · Potential for more than minimal harm 2023-06-08

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 2023-06-30

D · Potential for more than minimal harm 2023-06-08

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-06-30

D · Potential for more than minimal harm 2023-06-08

F758 · Pharmacy Service Deficiencies

Health

Corrected 2023-06-30

C · Minimal harm 2023-06-08

F851 · Administration Deficiencies

Health

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Corrected 2023-06-30

F · Potential for more than minimal harm 2021-11-02

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2021-11-30

E · Potential for more than minimal harm 2021-11-02

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 2021-11-30

D · Potential for more than minimal harm 2021-11-02

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 2021-11-30

D · Potential for more than minimal harm 2021-11-02

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 2021-11-30

Penalties and ownership