Inspection Reports for
Brookdale College Square
11000 OAKMONT ST, OVERLAND PARK, KS, 66210
Back to Facility ProfileDeficiencies (last 11 years)
Deficiencies (over 11 years)
2.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
60% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
73% occupied
Based on a September 2024 inspection.
Occupancy rate over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 24, 2026
Visit Reason
The visit was a resurvey with attached complaints to verify compliance and investigate multiple complaint allegations at the assisted living facility.
Complaint Details
The resurvey included attached complaints numbered 197862, 197773, 196537, 196438, 196115, 194067, 192164, and 192065. No citations were issued.
Findings
The resurvey conducted on 02/23/26 and 02/24/26 resulted in no citations or deficiencies.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 23, 2026
Visit Reason
This document is a plan of correction representing the findings of a resurvey with attached complaints conducted on 02/23/26 and 02/24/26 at an assisted living facility.
Findings
The resurvey and complaint investigation conducted on 02/23/26 and 02/24/26 resulted in no citations.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 9, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-09-23.
Findings
All deficiencies have been corrected as of the compliance date of 2024-09-25 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 9, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-09-23.
Findings
All deficiencies have been corrected as of the compliance date of 2024-09-25 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 41
Deficiencies: 1
Date: Sep 23, 2024
Visit Reason
The visit was a resurvey with attached complaints #188583, #186864, and #184634 at the assisted living facility.
Complaint Details
The resurvey was conducted with attached complaints #188583, #186864, and #184634.
Findings
The facility failed to ensure staff administered medications to Resident 1 in accordance with medical care provider orders, specifically regarding midodrine administration and blood pressure documentation.
Deficiencies (1)
KAR 26-41-205(d) Facility administration of medications. The facility staff administered midodrine to Resident 1 despite systolic blood pressures above 140 mm Hg and failed to document blood pressure results before medication administration.
Report Facts
Resident census: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Confirmed facility staff failed to administer midodrine according to medical orders. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
This document is a plan of correction representing the findings of a resurvey with attached complaints #188583, #186864, and #184634 conducted at the assisted living facility on 09/19/24 and 09/23/24.
Complaint Details
The resurvey included attached complaints #188583, #186864, and #184634.
Findings
The plan of correction addresses deficiencies identified during the resurvey and complaint investigations conducted on the specified dates. The document serves as the facility's response to these findings.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 5, 2023
Visit Reason
The abbreviated survey was conducted on 06/05/23 for complaints #180497, 180550, 180458, 180450, and 176794 at the assisted living facility.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 5, 2023
Visit Reason
The abbreviated survey was conducted on 06/05/2023 in response to multiple complaints (#180497, 180550, 180458, 180450, 176794) at the assisted living facility.
Complaint Details
The survey was complaint-related for multiple complaints and found no deficiencies.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 5, 2022
Visit Reason
The visit was an abbreviated survey conducted in response to multiple complaints at the assisted living facility.
Findings
The abbreviated survey conducted on 12/05/22 and 12/06/22 resulted in a finding of no deficiency citations.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 5, 2022
Visit Reason
The abbreviated survey was conducted in response to multiple complaint numbers received for the assisted living facility.
Complaint Details
The survey was complaint-related, covering complaints numbered 176480, 176448, 176267, 176254, 176057, 175606, 175323, and 175043. No deficiencies were cited.
Findings
The survey resulted in a finding of no deficiency citations at the facility.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 21, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 08/30/22.
Findings
All deficiencies have been corrected as of the compliance date of 09/13/22, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 21, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-08-30.
Findings
All deficiencies have been corrected as of the compliance date of 2022-09-13, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Renewal
Census: 64
Deficiencies: 2
Date: Aug 30, 2022
Visit Reason
The inspection was a licensure resurvey with attached complaint investigations for the facility conducted on 08/29/22 and 08/30/22.
Complaint Details
The inspection included complaint investigations for complaint numbers 174332, 173949, and 173563. The complaint related to an allegation of sexual abuse involving resident R112 was substantiated by the failure to report and investigate timely.
Findings
The facility failed to report an allegation of sexual abuse within 24 hours and did not submit the full investigation within five working days. Additionally, the facility failed to comply with tuberculosis (TB) testing guidelines for newly hired employees, missing required timing for the two-step TB skin tests.
Deficiencies (2)
K.A.R. 26-41-101 (f)(3)(E) The facility failed to report an allegation of sexual abuse involving resident R112 to the department within 24 hours and did not submit the full investigation within five working days after completion.
K.A.R. 26-41-207 (b)(5-6) (c) The facility failed to ensure compliance with tuberculosis guidelines by not performing the required two-step TB skin tests within the mandated timeframes for five newly hired employees.
Report Facts
Census: 64
Complaint numbers: 3
Sample residents: 6
Sample employees: 5
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 29, 2022
Visit Reason
The document is a plan of correction responding to findings from a licensure resurvey with attached complaint numbers 174332, 173949, and 173563 conducted on 08/29/22 and 08/30/22.
Findings
The plan of correction addresses citations found during the licensure resurvey and complaint investigations conducted on the specified dates.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 9, 2022
Visit Reason
The abbreviated resurvey was conducted in response to complaints #168144 and #165594 at the assisted living facility.
Complaint Details
The visit was complaint-related for complaints #168144 and #165594. No deficiencies were found.
Findings
The abbreviated resurvey resulted in a finding of no deficiency citations.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jun 7, 2021
Visit Reason
This revisit inspection was conducted to verify that previously cited deficiencies have been corrected by the facility.
Findings
The report confirms that the deficiencies previously reported under regulations 26-41-101 (f)(3) and 26-41-204 (a) have been corrected as of the revisit date.
Deficiencies (2)
Regulation 26-41-101 (f)(3): Previously cited deficiency corrected as of 06/07/2021.
Regulation 26-41-204 (a): Previously cited deficiency corrected as of 06/07/2021.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jun 7, 2021
Visit Reason
This visit was conducted as a follow-up to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
The report confirms that the deficiencies previously cited under regulations 26-41-101 (f)(3) and 26-41-204 (a) have been corrected as of the revisit date.
Deficiencies (2)
Regulation 26-41-101 (f)(3) deficiency was corrected as of 06/07/2021.
Regulation 26-41-204 (a) deficiency was corrected as of 06/07/2021.
Inspection Report
Re-Inspection
Census: 44
Deficiencies: 2
Date: May 12, 2021
Visit Reason
The inspection was conducted for re-licensure with attached complaints on multiple dates in May 2021 at an assisted living facility in Overland Park, KS.
Complaint Details
The inspection included attached complaints #42554, #49735, #51873, #55100, and #61881. The allegations involved inappropriate sexual behavior by resident #111 towards other residents, which were not reported or investigated timely by the facility.
Findings
The facility failed to immediately implement corrective measures to prevent further potential sexual abuse, failed to report allegations of abuse within 24 hours, and failed to initiate timely investigations. A resident with dementia exhibited inappropriate sexual behaviors towards multiple female residents, and the facility did not adequately address these behaviors or coordinate necessary health care services, placing residents at immediate jeopardy.
Deficiencies (2)
KAR 26-41-101 (f)(3) Staff Treatment of Residents Reporting: The operator failed to immediately implement corrective measures, report allegations of abuse within 24 hours, and initiate investigations for incidents involving inappropriate sexual behavior by resident #111.
KAR 26-41-204 (a) Health Care Services: The operator failed to ensure a licensed nurse provided or coordinated necessary health care services to meet the needs of residents, including addressing inappropriate sexual behaviors of resident #111.
Report Facts
Resident census: 44
Dates of incidents: Multiple dates of incidents involving resident #111's inappropriate behavior from 02/11/2021 through 04/30/2021.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse #B | Administrative Nurse | Confirmed receipt of resident records and acknowledged failure to report incidents within 24 hours. |
| CNA #C | Certified Nursing Assistant | Provided notarized statement describing observation of inappropriate touching by resident #111. |
| Activity Staff #D | Activity Staff | Provided notarized statement describing observation of resident #111 near another resident with unbuttoned clothing. |
| Operator #A | Operator | Provided notarized statement regarding plans for resident #111's placement and supervision. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 12, 2021
Visit Reason
This document is a plan of correction related to deficiencies identified in a prior inspection of the facility.
Findings
No specific findings or deficiencies are detailed in this document; it serves as a record of the plan of correction submission and modification dates.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 8, 2021
Visit Reason
The abbreviated resurvey was conducted for complaints #168144 and #165594 at the assisted living facility.
Findings
The abbreviated resurvey resulted in a finding of no deficiency citations.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 7, 2020
Visit Reason
The facility underwent a special infection control survey for COVID-19 on August 7, 2020.
Findings
The survey resulted in findings of no deficiency citations related to infection control.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 24, 2019
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified as RCUM12 for the facility with State ID N046047.
Findings
No deficiency details or findings are included in this Plan of Correction document. It only references the related deficiency report but states no records found.
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Jan 16, 2019
Visit Reason
This visit was a follow-up to verify correction of previously cited deficiencies at the facility.
Findings
The report shows that previously reported deficiencies identified by regulation numbers 26-41-102 (d) and 26-41-207 (b) (5-6) (c) were corrected as of the revisit date.
Deficiencies (2)
Regulation 26-41-102 (d) deficiency was corrected as of 01/16/2019.
Regulation 26-41-207 (b) (5-6) (c) deficiency was corrected as of 01/16/2019.
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Jan 16, 2019
Visit Reason
This is a follow-up visit to verify correction of previously reported deficiencies at Brookdale College Square.
Findings
The report documents that previously cited deficiencies under regulations 26-41-102(d) and 26-41-207(b)(5-6)(c) have been corrected as of the revisit date.
Deficiencies (2)
Regulation 26-41-102(d) deficiency was corrected as of 2019-01-16.
Regulation 26-41-207(b)(5-6)(c) deficiency was corrected as of 2019-01-16.
Inspection Report
Renewal
Census: 56
Deficiencies: 2
Date: Dec 13, 2018
Visit Reason
The survey was conducted for re-licensure with attached complaints at the assisted living facility in Overland Park, KS on 12/11/18, 12/12/18, and 12/13/18.
Findings
The operator failed to ensure employee records contained required documentation for criminal background checks and nurse aide registry verification prior to employment. The facility also failed to comply with tuberculosis guidelines for adult care homes, lacking required TB skin tests and documentation for recent staff.
Deficiencies (2)
26-41-102 (d) Staff Qualifications Employee Records: The operator failed to ensure employee records contained supporting documentation from the nurse aide registry and criminal background checks prior to employment for 4 certified staff.
26-41-207 (b) (5-6) (c) Infection Control Policies: The operator failed to ensure compliance with tuberculosis guidelines, lacking facility TB skin tests and documentation for recent staff hires.
Report Facts
Census: 56
Sample residents reviewed: 4
Days delay for KBI check: 16
Days delay for KBI check: 9
Days delay for KBI check: 2
Days delay for KBI check: 1
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 8
Date: Nov 8, 2016
Visit Reason
Licensure Resurvey and complaint investigation #94773 at Brookdale College Square, a Residential Health Care Facility in Overland Park, Kansas.
Complaint Details
Complaint #94773 was investigated during the licensure resurvey.
Findings
The facility failed to ensure resident privacy related to the use of audio electronic monitors, accurate functional capacity screenings, timely and accurate negotiated service agreements, proper health care service coordination by licensed nurses, complete documentation of incidents, and quarterly emergency preparedness reviews with employees and residents.
Deficiencies (8)
KAR 26-39-103(i)(1) The Operator failed to develop and implement policy and procedure to ensure residents' privacy and confidentiality during medical and nursing treatment, personal care, visits, and meetings related to the use of audio electronic monitors transmitting sounds to open kitchens.
KAR 26-41-201(d) The Operator failed to ensure designated staff completed functional capacity screens that accurately reflected residents' current functional abilities for two sampled residents.
KAR 26-41-202(d) The Operator failed to ensure review and revision of negotiated service agreements following significant changes in condition for one sampled resident.
KAR 26-41-202(h) The Operator failed to ensure all individuals involved in the development of negotiated service agreements signed the agreements for six residents.
KAR 26-41-204(a) The Operator failed to ensure a licensed nurse provided or coordinated necessary health care services meeting residents' needs for one sampled resident.
KAR 26-41-204(d) The Operator failed to ensure negotiated service agreements contained descriptions of health care services and the name of the licensed nurse responsible for implementation and supervision for four residents.
KAR 26-41-105(f)(11) The Operator failed to ensure resident records contained documentation of all incidents, symptoms, and other indications of illness or injury including date, time, action taken, and results for one sampled resident.
KAR 26-41-104(d) The Operator failed to ensure quarterly reviews of the facility's emergency management plan were conducted with both employees and residents.
Report Facts
Resident census: 51
Employees hired since last resurvey: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Operator L | Interviewed regarding use of audio electronic monitors and emergency management plan. | |
| Health and Wellness Director M | Interviewed regarding functional capacity screens, negotiated service agreements, health care services, and emergency management plan. | |
| Licensed Practical Nurse Q | LPN | Observed providing care to Resident #189 and interviewed about fall prevention plan. |
| Certified Staff P | Observed assisting Residents #185 and #187 with transfers and personal care. | |
| Certified Staff K | Observed assisting Resident #185 with transfers and personal care. | |
| Certified Staff F | Observed assisting Resident #187 and Resident #189 with care and fall prevention. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 19, 2014
Visit Reason
This document is a Plan of Correction submitted in response to a prior inspection event identified as W39A11 for facility State ID N046047 ASPEN.
Findings
No deficiencies or findings are detailed in this document. It serves solely as a record of the Plan of Correction submission with no linked deficiency report found.
Inspection Report
Renewal
Census: 42
Deficiencies: 3
Date: Dec 11, 2014
Visit Reason
Licensure Resurvey conducted at the Residential Health Care Facility to assess compliance with state regulations and licensing requirements.
Findings
The facility failed to conduct functional capacity screenings following significant changes in resident conditions and failed to develop complete negotiated service agreements (NSA) for sampled residents, including missing descriptions of services and required signatures.
Deficiencies (3)
KAR 26-41-201(c)(2) Functional Capacity Screen Reassessment: The facility failed to ensure designated staff conducted screenings to determine residents' functional capacity following significant changes in condition for two of three sampled residents (#189 and #187).
KAR 26-41-202(a) Negotiated Service Agreement: The facility failed to develop written negotiated service agreements for three sampled residents (#189, #187, and #185) that included descriptions of the services the residents were to receive.
KAR 26-41-202(h) NSA Signatures: The facility failed to ensure that all individuals involved in the development of the negotiated service agreements for two sampled residents (#189 and #185) signed the agreements.
Report Facts
Census: 42
Sampled residents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Facility Nurse G | Facility Nurse | Confirmed significant changes in resident conditions and missing documentation in functional capacity screens and negotiated service agreements. |
| Operator C | Operator | Confirmed missing signatures on negotiated service agreements and lack of documentation for attempts to obtain signatures. |
| Hospice staff N | Hospice Staff | Provided care and assisted resident #187; noted in observations and interviews. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 1, 2012
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified as 95T811 for the facility with State ID N046047.
Findings
No deficiency records or findings are included in this Plan of Correction document.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046047 POC 6QSY11
Visit Reason
This document is a Plan of Correction related to a previous deficiency report for Brookdale College Square.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the Plan of Correction submission and modification dates.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046047 POC 8TFJ12
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No deficiency details or findings are included in this document. It only references the Plan of Correction status and contact information for assistance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046047 POC BBDW11
Visit Reason
This document is a Plan of Correction related to a prior inspection or regulatory event for the facility identified as ASPEN with State ID N046047.
Findings
No deficiency records or findings are included in this Plan of Correction document. It serves as a corrective action response to previous inspection findings.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046047 POC C5JZ11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility Brookdale College Square.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the Plan of Correction submission and modification dates.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046047 POC GEPE11
Visit Reason
This document is a Plan of Correction related to a previous deficiency report for Brookdale College Square concerning a COVID-19 related inspection dated 8.7.2020.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046047 POC H37211
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No deficiency details or findings are included in this document. It only references the Plan of Correction status and contact information for assistance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046047 POC H37212
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified by Event ID H37212 for the facility with State ID N046047.
Findings
No deficiency records or findings are included in this Plan of Correction document.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046047 POC RCUM11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the Plan of Correction submission and modification dates.
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