Cycle 1
Health 2024-05-08 · Fire 2024-05-08
7 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Overland Park, KS
Tallgrass Creek, Inc
5-star overall rating with 4-star inspections with $7,446 in total fines with 7 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
13760 Metcalf Avenue, Overland Park, KS
(913) 945-2350
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
44
Certified beds
Average residents
39
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Erickson Senior Living
Operator or chain grouping
Approved since
2014-05-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 4 overall / 3 health / 5 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
1.21
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.60
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.79
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
4.17
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.60
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
1.27
CMS adjusted RN staffing hours
Adjusted total hours
5.03
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
15%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,387
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
57.06
Composite VBP score used to determine payment impact.
Payment multiplier
1.0122
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.54
Performance 18.87% · Measure score 5.54 · Achievement 5.54 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.12
Baseline 6.50% · Performance 6.90% · Measure score 3.12 · Achievement 3.12 · Improvement 0
Total nurse turnover
4.16
Baseline 45.28% · Performance 46.67% · Measure score 4.16 · Achievement 4.16 · Improvement 0
Adjusted total nurse staffing
10
Baseline 4.48 hours · Performance 5.81 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.35% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 64 · Observed rate 12.5% · Lower 95% interval 8.28% |
| Discharge to community | 49.18% |
50.57%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 61 · Observed rate 40.98% · Lower 95% interval 40.39% |
| Medicare spending per beneficiary | 0.76 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 47 · Denominator 47 |
| Falls with major injury | 2.13% |
0.77%
1.4 pts worse
|
Numerator 1 · Denominator 47 |
| Discharge self-care score | 68.29% |
53.69%
14.6 pts better
|
Numerator 28 · Denominator 41 |
| Discharge mobility score | 48.78% |
50.94%
2.2 pts worse
|
Numerator 20 · Denominator 41 |
| Pressure ulcers or injuries, new or worsened | 4.26% |
2.29%
2 pts worse
|
Numerator 2 · Denominator 47 · Adjusted rate 5.72% |
| Healthcare-associated infections requiring hospitalization | 6.9% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 37 · Observed rate 5.41% · Lower 95% interval 3.55% |
| Staff COVID-19 vaccination coverage | 1.09% |
8.2%
7.1 pts worse
|
Numerator 1 · Denominator 92 |
| Staff flu vaccination coverage | 27.43% |
42%
14.6 pts worse
|
Numerator 48 · Denominator 175 |
| Discharge function score | 51.22% |
56.45%
5.2 pts worse
|
Numerator 21 · Denominator 41 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 95.65% |
96.28%
0.6 pts worse
|
Numerator 22 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 54.84% |
25.2%
29.6 pts better
|
Numerator 17 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
1.8
1.3 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.5 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
2.2
1.7 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
91.8%
6.7 pts better
|
93.4%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 96.9% · Q4 96.9% · 4Q avg 98.5% |
| 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 | 4.5% |
4.4%
0.1 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 2.9% · Q3 6.2% · Q4 3.1% · 4Q avg 4.5% · 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 | 2.5% |
5.0%
2.5 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 4.3% · Q3 0.0% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.5% |
23.2%
6.7 pts better
|
19.6%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 12.5% · Q3 18.2% · 4Q avg 16.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.1% |
19.8%
8.7 pts better
|
16.7%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 10.0% · 4Q avg 11.1% · 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 | 26.1% |
18.4%
7.7 pts worse
|
16.3%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.5% |
18.8%
4.3 pts better
|
14.9%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 14.3% · 4Q avg 14.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.8%
1.1 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.7% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
3.1%
1.6 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 0.0% · Q4 3.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.1% |
23.2%
0.1 pts better
|
19.8%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 28.4% · Q3 23.9% · Q4 24.4% · 4Q avg 23.1% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
4.6%
0.2 pts worse
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 8.4% · Q3 5.0% · Q4 3.6% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.5% |
75.6%
9.9 pts better
|
81.7%
3.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 84.9% · Q2 88.7% · Q3 85.0% · Q4 83.6% · 4Q avg 85.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.5% |
11.7%
2.8 pts worse
|
12.0%
2.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.5% · Observed 14.3% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.6% |
2.2%
2.4 pts worse
|
1.6%
3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 6.1% · Q3 5.6% · Q4 2.6% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.9% |
73.5%
21.4 pts better
|
79.7%
15.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.8% |
23.0%
2.8 pts worse
|
23.9%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.8% · Observed 20.0% · Expected 18.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-27 · Fire 2022-10-27
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-06-23 · Fire 2021-06-23
4 health deficiencies
Top issue: Infection Control (2 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-05-08
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 2024-07-18
F · Potential for more than minimal harm
2024-05-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-26
F · Potential for more than minimal harm
2024-05-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-18
F · Potential for more than minimal harm
2024-05-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-25
E · Potential for more than minimal harm
2024-05-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-18
E · Potential for more than minimal harm
2024-05-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-23
E · Potential for more than minimal harm
2024-05-08
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2024-07-18
E · Potential for more than minimal harm
2024-05-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-07-18
E · Potential for more than minimal harm
2024-05-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-07-18
F · Potential for more than minimal harm
2022-10-27
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2023-01-06
F · Potential for more than minimal harm
2022-10-27
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-01-06
F · Potential for more than minimal harm
2022-10-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-01-06
F · Potential for more than minimal harm
2022-10-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-01-06
F · Potential for more than minimal harm
2022-10-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-06
F · Potential for more than minimal harm
2022-10-27
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-01-06
F · Potential for more than minimal harm
2022-10-27
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-01-06
F · Potential for more than minimal harm
2022-10-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-06
E · Potential for more than minimal harm
2022-10-27
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 2023-01-06
E · Potential for more than minimal harm
2022-10-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-06
D · Potential for more than minimal harm
2022-10-27
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-01-06
D · Potential for more than minimal harm
2022-10-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-01-06
F · Potential for more than minimal harm
2021-06-23
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2021-09-03
F · Potential for more than minimal harm
2021-06-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-09-03
F · Potential for more than minimal harm
2021-06-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-09-03
F · Potential for more than minimal harm
2021-06-23
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2021-09-03
E · Potential for more than minimal harm
2021-06-23
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 2021-09-03
E · Potential for more than minimal harm
2021-06-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-09-03
D · Potential for more than minimal harm
2021-06-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-09-03
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-05-08
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 2024-06-11
E · Potential for more than minimal harm
2024-05-08
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-06-11
E · Potential for more than minimal harm
2024-05-08
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 2024-06-11
E · Potential for more than minimal harm
2024-05-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-11
D · Potential for more than minimal harm
2024-05-08
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 2024-06-11
D · Potential for more than minimal harm
2024-05-08
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-06-11
D · Potential for more than minimal harm
2024-05-08
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 2024-06-11
J · Immediate jeopardy
2023-10-16
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 2023-10-12
E · Potential for more than minimal harm
2022-10-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-10-27
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 2022-12-08
D · Potential for more than minimal harm
2022-10-27
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-10-27
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 2022-12-08
D · Potential for more than minimal harm
2022-10-27
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 2022-12-08
D · Potential for more than minimal harm
2022-10-27
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 2022-12-08
E · Potential for more than minimal harm
2021-06-23
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 2021-07-23
E · Potential for more than minimal harm
2021-06-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-07-23
D · Potential for more than minimal harm
2021-06-23
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2021-07-23
Penalties and ownership
What sits behind the stars
$7,446
2023-10-16
Fine
Fine · fine $7,446
Fine
Ownership
National Senior Communities, Inc
5% Or Greater Direct Ownership Interest · Organization
Oak Investment Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Oak Investment Trust
5% Or Greater Indirect Ownership Interest · Organization
Belcher, Wendy
Operational/Managerial Control · Individual
Brown, Ian
Corporate Director · Individual
Brown, Patricia
Corporate Director · Individual
Butler, Richard
Operational/Managerial Control · Individual
Clupper, Katherine
Corporate Director · Individual
Colins, Mary
Corporate Director · Individual
Colins, Mary
Corporate Officer · Individual
Embley, Mark
Operational/Managerial Control · Individual
Embley, Mark
Corporate Officer · Individual
Erickson Senior Living LLC
Operational/Managerial Control · Organization
Erstad, Eileen
Corporate Director · Individual
Erstad, Eileen
Corporate Officer · Individual
Gantert, Neal
Operational/Managerial Control · Individual
Gantert, Neal
Corporate Officer · Individual
Hall, John
Operational/Managerial Control · Individual
Hall, John
Corporate Officer · Individual
Jacque, Zina
Corporate Director · Individual
Leonard, Monty
Corporate Director · Individual
Martin, Sonya
Operational/Managerial Control · Individual
Moscato, Mary
Corporate Director · Individual
National Senior Communities, Inc
Operational/Managerial Control · Organization
Paulk, Pamela
Corporate Director · Individual
Pomeranz, William
Corporate Director · Individual
Pomeranz, William
Corporate Officer · Individual
Reel, Stephanie
Corporate Director · Individual
Roskiewicz, Michael
Corporate Director · Individual
Roskiewicz, Michael
Corporate Officer · Individual
Sawicki, Scott
Corporate Officer · Individual
Sharp, Russel
Corporate Director · Individual
Stiner, Pamela
Operational/Managerial Control · Individual
Stiner, Pamela
Corporate Officer · Individual
Sweetser, Christian
Operational/Managerial Control · Individual
Tyler, Daniel
Corporate Officer · Individual
Wallick, Daniel
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
The Healthcare Resort Of Leawood - Iron Horse Hlth
Leawood, KS
3-star overall rating with 2-star inspections with 14 recent health deficiencies with 4 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
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
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