Cycle 1
Health 2025-05-14 · Fire 2025-05-14
3 health deficiencies
Top issue: Infection Control (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Olathe, KS
Hoeger House
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
20911 West 153rd Street, Olathe, KS
(913) 397-2900
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
34
Certified beds
Average residents
34
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Good Samaritan Society
Operator or chain grouping
Approved since
2006-10-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
89 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.45
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.37
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.56
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
2.19
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.10
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.99
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.41
CMS adjusted RN staffing hours
Adjusted total hours
4.46
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,847
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.44
Composite VBP score used to determine payment impact.
Payment multiplier
0.9954
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.89% · Performance 22.00% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
7.49
Baseline 5.13% · Performance 5.60% · Measure score 7.49 · Achievement 7.49 · Improvement 0
Total nurse turnover
4.63
Baseline 44.12% · Performance 44.74% · Measure score 4.63 · Achievement 4.63 · Improvement 0
Adjusted total nurse staffing
4.85
Baseline 4.16 hours · Performance 4.46 hours · Measure score 4.85 · Achievement 4.85 · Improvement 1.34
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.33% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 232 · Observed rate 10.78% · Lower 95% interval 8.57% |
| Discharge to community | 58.55% |
50.57%
8 pts better
|
Better than the National Rate · Eligible stays 225 · Observed rate 56.89% · Lower 95% interval 53.1% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 154 · Denominator 154 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 154 |
| Discharge self-care score | 71.05% |
53.69%
17.4 pts better
|
Numerator 81 · Denominator 114 |
| Discharge mobility score | 69.3% |
50.94%
18.4 pts better
|
Numerator 79 · Denominator 114 |
| Pressure ulcers or injuries, new or worsened | 0.65% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 154 · Adjusted rate 0.8% |
| Healthcare-associated infections requiring hospitalization | 5.6% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 135 · Observed rate 2.96% · Lower 95% interval 3% |
| Staff COVID-19 vaccination coverage | 6.45% |
8.2%
1.7 pts worse
|
Numerator 4 · Denominator 62 |
| Staff flu vaccination coverage | 88.14% |
42%
46.1 pts better
|
Numerator 52 · Denominator 59 |
| Discharge function score | 71.05% |
56.45%
14.6 pts better
|
Numerator 81 · Denominator 114 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 42 · Denominator 42 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 99 · Denominator 99 |
| Resident COVID-19 vaccinations up to date | 41.25% |
25.2%
16.1 pts better
|
Numerator 33 · Denominator 80 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
75.6%
24.2 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.6% · Q4 99.6% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.9% |
11.7%
3.8 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 8.6% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
2.2%
1.7 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.0% · Q3 0.6% · Q4 0.6% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
73.5%
26.5 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.2% |
23.0%
1.2 pts worse
|
23.9%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.2% · Observed 26.4% · Expected 26.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-31 · Fire 2023-08-31
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
24 fire-safety deficiencies
Top issue: Emergency Preparedness (14 deficiencies)
Cycle 3
Health 2022-01-27 · Fire 2022-01-27
10 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-08-26
F · Potential for more than minimal harm
2025-05-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-26
F · Potential for more than minimal harm
2025-05-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-08-26
E · Potential for more than minimal harm
2025-05-14
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 2025-08-26
E · Potential for more than minimal harm
2025-05-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-08-26
E · Potential for more than minimal harm
2025-05-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-08-26
E · Potential for more than minimal harm
2025-05-14
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-08-26
E · Potential for more than minimal harm
2025-05-14
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 2025-08-26
F · Potential for more than minimal harm
2023-08-31
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-11-16
F · Potential for more than minimal harm
2023-08-31
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2023-11-16
F · Potential for more than minimal harm
2023-08-31
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2023-11-16
F · Potential for more than minimal harm
2023-08-31
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2023-11-16
F · Potential for more than minimal harm
2023-08-31
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2023-11-16
F · Potential for more than minimal harm
2023-08-31
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-11-16
F · Potential for more than minimal harm
2023-08-31
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2023-11-16
F · Potential for more than minimal harm
2023-08-31
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2023-11-16
F · Potential for more than minimal harm
2023-08-31
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-11-16
F · Potential for more than minimal harm
2023-08-31
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-11-16
F · Potential for more than minimal harm
2023-08-31
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-11-16
F · Potential for more than minimal harm
2023-08-31
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-11-16
F · Potential for more than minimal harm
2023-08-31
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-11-16
F · Potential for more than minimal harm
2023-08-31
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2023-11-16
F · Potential for more than minimal harm
2023-08-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-11-16
F · Potential for more than minimal harm
2023-08-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-11-16
F · Potential for more than minimal harm
2023-08-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-16
F · Potential for more than minimal harm
2023-08-31
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-11-16
F · Potential for more than minimal harm
2023-08-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-16
F · Potential for more than minimal harm
2023-08-31
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-11-16
F · Potential for more than minimal harm
2023-08-31
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2023-11-16
F · Potential for more than minimal harm
2023-08-31
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 2023-11-16
F · Potential for more than minimal harm
2023-08-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-16
E · Potential for more than minimal harm
2023-08-31
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-11-16
F · Potential for more than minimal harm
2022-01-27
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2022-04-20
F · Potential for more than minimal harm
2022-01-27
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-04-20
F · Potential for more than minimal harm
2022-01-27
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-04-20
F · Potential for more than minimal harm
2022-01-27
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2022-04-20
F · Potential for more than minimal harm
2022-01-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-04-20
F · Potential for more than minimal harm
2022-01-27
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-04-20
F · Potential for more than minimal harm
2022-01-27
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-04-20
F · Potential for more than minimal harm
2022-01-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-04-20
E · Potential for more than minimal harm
2022-01-27
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-04-20
E · Potential for more than minimal harm
2022-01-27
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 2022-04-20
E · Potential for more than minimal harm
2022-01-27
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-04-20
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-14
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 2025-06-24
D · Potential for more than minimal harm
2025-05-14
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-06-24
D · Potential for more than minimal harm
2025-05-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-24
G · Actual harm
2023-08-31
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 2023-07-21
F · Potential for more than minimal harm
2023-08-31
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 2023-10-01
F · Potential for more than minimal harm
2023-08-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-01
D · Potential for more than minimal harm
2023-08-31
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-01
D · Potential for more than minimal harm
2023-08-31
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 2023-10-01
D · Potential for more than minimal harm
2023-08-31
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 2023-10-01
D · Potential for more than minimal harm
2023-08-31
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 2023-10-01
E · Potential for more than minimal harm
2022-01-27
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-03-10
E · Potential for more than minimal harm
2022-01-27
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 2022-03-10
E · Potential for more than minimal harm
2022-01-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-10
D · Potential for more than minimal harm
2022-01-27
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-03-10
D · Potential for more than minimal harm
2022-01-27
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-03-10
D · Potential for more than minimal harm
2022-01-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-03-10
D · Potential for more than minimal harm
2022-01-27
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-03-10
D · Potential for more than minimal harm
2022-01-27
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-03-10
D · Potential for more than minimal harm
2022-01-27
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2022-03-10
D · Potential for more than minimal harm
2022-01-27
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2022-03-10
Penalties and ownership
What sits behind the stars
Ownership
Cedar Lake Village Inc
5% Or Greater Direct Ownership Interest · Organization
Olathe Medical Center Inc
5% Or Greater Indirect Ownership Interest · Organization
The Evangelical Lutheran Good Samaritan Society
5% Or Greater Indirect Ownership Interest · Organization
Bowen, John
Corporate Director · Individual
Bradley, James
Corporate Director · Individual
Fitzgerald, Randy
Corporate Director · Individual
Fitzgerald, Randy
Corporate Officer · Individual
Herdina, Joseph
Corporate Director · Individual
Herdina, Joseph
Corporate Officer · Individual
Karas, Alexandria
W-2 Managing Employee · Individual
Syverson, Thomas
Operational/Managerial Control · Individual
Syverson, Thomas
Corporate Director · Individual
Syverson, Thomas
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Good Samaritan Society - Olathe
Olathe, KS
3-star overall rating with 2-star inspections with 17 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
The Healthcare Resort Of Olathe
Olathe, KS
2-star overall rating with 1-star inspections with $53,279 in total fines with 13 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Azria Health Olathe
Olathe, KS
1-star overall rating with 1-star inspections with abuse icon flag with $22,617 in total fines with 17 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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