Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aberdeen Village during CMS and state inspections, most recent first.
Failure to individualize dementia care for a resident with severe cognitive impairment and daily wandering. The resident repeatedly wandered into other residents’ rooms, was exit seeking, and at times was difficult to redirect. Records and staff interviews described an incident where a CNA found the resident next to another resident’s bed with apparent touching, while the resident insisted the other resident was his wife. The care plan addressed general wandering and redirection but did not include specific interventions for repeated room intrusion.
A resident with Alzheimer’s disease, prior stroke, insomnia, and major depressive disorder was maintained on Quetiapine for “unspecified dementia with psychotic disturbances” without a CMS-approved indication and without behavioral monitoring. The MDS showed severe cognitive impairment but no documented behaviors, and the care plan referenced resisting care and yelling out but did not include a clear psychiatric indication for antipsychotic use. The resident was observed calm and behavior-free, while the EMR lacked behavior tracking tied to the antipsychotic. A consultant pharmacist recommended gradual dose reduction, which the provider declined, and staff acknowledged that antipsychotics are not indicated for dementia alone and that the resident’s representative refused medication changes, leaving the facility unable to document an appropriate rationale consistent with its own psychotropic medication policy.
Surveyors found that a resident was maintained on Quetiapine for an indication of unspecified dementia with psychotic disturbances without a clearly documented CMS-approved psychiatric indication. The MDS showed no documented behaviors during the assessment period, and the care plan referenced behaviors and use of Quetiapine but did not specify a psychiatric indication or include behavioral monitoring. The consultant pharmacist’s monthly reviews recommended gradual dose reduction, which the provider declined, but did not address the inappropriate dementia-related indication, and the facility could not produce documentation supporting an appropriate indication despite acknowledging that antipsychotics are not indicated for dementia alone.
A resident with Alzheimer's and moderate cognitive impairment eloped from a facility due to inadequate supervision and unsecured exits. The resident, who required assistance for ambulation and was at risk for falls, left the facility unnoticed and was found by law enforcement at a nearby gas station. The facility's elopement risk assessment did not identify the resident as at risk, and the care plan did not address elopement potential.
The facility failed to follow sanitary dietary standards, including improper food storage, lack of temperature log checks, and inadequate hand hygiene by dietary staff, placing residents at risk of foodborne illnesses.
The facility failed to store medications and biologicals appropriately when the medication room was found unlocked and a resident's insulin pens were not labeled with the open date. Staff were expected to ensure the medication room was locked at all times and insulin pens were labeled and stored properly.
The facility failed to ensure adequate infection control standards, including the use of enhanced barrier precautions, PPE, and proper indwelling catheter maintenance. Inspections revealed missing signage and PPE in residents' rooms and improper handling of a urinary catheter bag. Staff acknowledged awareness of the requirements but did not consistently implement them, placing residents at risk for infections.
The facility failed to honor a resident's request to move to the TV room during breakfast and did not maintain another resident's dignity during transfers in a common area, leading to exposure. Staff ignored the first resident's repeated requests and did not assist him, while the second resident was exposed during transfers due to improper handling by the staff.
The facility failed to ensure a resident received necessary assistive services for transfers, leading to the use of a gait belt that exposed the resident's skin and did not provide adequate support. Staff were inconsistent in following the care plan, which indicated the use of a pivot disc and walker.
The facility failed to ensure a resident's low air-loss mattress pump was set correctly according to their weight, and did not complete weekly wound assessments for another resident with a pressure ulcer. These deficiencies placed the residents at risk for complications related to skin breakdown and pressure ulcers.
A facility failed to provide appropriate treatment for a resident with an indwelling catheter by allowing the catheter drainage bag to rest on the floor. The resident had a history of frequent UTIs and required assistance for proper hygiene. Observations and staff interviews confirmed the improper placement of the catheter bag, which should have been stored in a dignity bag attached to the bed.
A resident's CPAP mask was repeatedly observed to be laid directly on the bedside table without containment, contrary to facility policy. Staff interviews confirmed the improper storage practice, which increased the resident's risk for respiratory infection and complications.
The facility failed to identify a resident's low air-loss mattress and bolstered overlay as potential risks in the side rail assessment, placing the resident at risk for inadequate care due to unidentified care needs. Staff were unsure if the assessments differentiated between mattress types and overlays, contrary to facility policy.
Failure to Individualize Dementia Care for Wandering and Room Intrusion
Penalty
Summary
The facility failed to provide individualized care and services for a resident with dementia who displayed daily wandering and exit-seeking behaviors, including entering other residents’ rooms. The resident’s record documented diagnoses of dementia, severe cognitive impairment, anxiety, PTSD, adjustment disorder, muscle weakness, and cognitive communication deficit. The care plan identified wandering and exit-seeking, use of a WanderGuard, redirection, cueing, supervision, and structured activities, but it did not include interventions specifically addressing the resident’s repeated wandering into other residents’ rooms. The resident was repeatedly documented wandering in hallways and entering other residents’ rooms, especially later in the day and overnight. Notes described the resident as confused, exit seeking, difficult to redirect at times, and looking for keys or a way to leave. One behavior note documented the resident walking out of another resident’s room without pants on and needing staff assistance with hygiene after being found in a soiled bathroom. Another note documented the resident wandering into rooms at the beginning of a shift and stating he was looking for his keys so he could leave. A facility investigation documented an incident in which a CNA found the resident standing next to another resident’s bed and appearing to touch that resident’s abdominal area while the resident was lying in bed with clothing partially down. The resident refused to leave at first and stated the other resident was his wife. Additional staff interviews confirmed the resident frequently wandered into other residents’ rooms, sometimes tried to physically help them, and staff commonly redirected him or allowed him to remain until he left on his own. Staff also stated there were no other specific interventions added for the resident’s wandering into rooms beyond observation and redirection.
Inappropriate Antipsychotic Use Without CMS-Approved Indication
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure a resident remained free from chemical restraint through the inappropriate use of an antipsychotic medication without a CMS-approved indication. The resident had diagnoses including Alzheimer’s disease, cerebral infarction, insomnia, and major depressive disorder, with a BIMS score indicating severe cognitive impairment but no documented behaviors on the MDS during the assessment period. The care plan, initiated months earlier, described behaviors of resisting care and yelling out related to depression, anxiety, and dementia, and noted the use of Quetiapine (Seroquel) for these behaviors, but it did not include a psychiatric indication for the antipsychotic. The physician’s order renewed Quetiapine 12.5 mg daily for “unspecified dementia with psychotic disturbances,” and the resident had been admitted on this medication and diagnosis. Record review showed no behavioral monitoring related to the antipsychotic use, despite the resident’s psychotropic CAA identifying antipsychotic use and risk for adverse effects. Consultant pharmacist documentation over several months included a recommendation for gradual dose reduction of Quetiapine, which the provider declined, citing risk of decompensation, but the recommendations did not address the lack of an appropriate CMS indication for use in dementia. The facility was unable to provide a documented rationale for continued Quetiapine use without an appropriate CMS indication when requested. Observations showed the resident calm, engaged in group activity, and without behaviors at the time of surveyor observation. Interviews with facility staff confirmed that antipsychotics are not indicated for dementia alone and that dementia was the listed indication, with staff acknowledging that the resident’s representative refused changes to the medication or its indication. The facility’s own policy required psychotropic drugs to be used with specific diagnoses and to be closely monitored, but this was not supported by the documentation for this resident’s antipsychotic therapy.
Failure to Ensure Appropriate CMS-Approved Indication for Antipsychotic Therapy
Penalty
Summary
Surveyors identified a deficiency in the facility’s drug regimen review process related to the use of an antipsychotic medication for a resident with dementia. The resident’s EMR listed diagnoses of Alzheimer’s disease, cerebral infarction, insomnia, and major depressive disorder, with a BIMS score indicating severe cognitive impairment. The MDS showed the resident was independent in activities of daily living and did not exhibit behaviors during the assessment period, though it documented antipsychotic use. The CAA noted antipsychotic use and risk for adverse effects from Seroquel. The care plan, initiated earlier, described behaviors of resisting care and yelling out related to depression, anxiety, and dementia, and stated that Quetiapine (Seroquel) was used for these behaviors, but it lacked a clear psychiatric indication for the medication. The EMR contained a renewed order for Quetiapine 12.5 mg daily with an indication of unspecified dementia with psychotic disturbances, and there was no behavioral monitoring documented related to the antipsychotic use. Review of the consultant pharmacist’s monthly recommendations from May through February showed that the pharmacist recommended a gradual dose reduction of Quetiapine to the lowest effective dose, which the medical provider declined, citing risk of decompensation. The pharmacist’s recommendations did not address the use of the antipsychotic with the indication of dementia, and the facility could not provide documentation supporting a CMS-approved indication for the continued use of Quetiapine despite a request for such rationale. Observations showed the resident calm and engaged in group activity without behaviors. Interviews revealed that the consultant pharmacist stated the resident was admitted on the antipsychotic and that the representative refused changes or discontinuation, and that the medication was believed to be needed for dementia-related hallucinations and delusions. A nurse and an administrative nurse both stated that antipsychotics were not indicated for dementia alone and required a psychiatric diagnosis, and that the resident had been admitted with the medication and dementia diagnosis. This sequence of actions and inactions demonstrated a failure to ensure the consultant pharmacist addressed the lack of an appropriate CMS indication for the antipsychotic during the monthly drug regimen review, contrary to the facility’s drug regimen review policy.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a cognitively impaired resident, who required staff assistance for activities of daily living, including safe ambulation with a walker, and was at risk for falls. On the early morning of 10/17/24, a Certified Nurse Aide (CNA) heard the resident's toilet flush and checked on her. The resident indicated she did not need assistance, and the CNA left to assist another resident, assuming the resident would return to bed. However, the resident subsequently left her room, took the elevator to the first floor, and exited the facility without staff knowledge or supervision. The resident, who had a diagnosis of Alzheimer's disease, unspecified dementia, osteoporosis, syncope, and a history of falls, was found by law enforcement at a nearby gas station and returned to the facility. The resident's electronic medical record indicated moderate cognitive impairment and a need for supervision during ambulation. Despite these needs, the resident's care plan did not address elopement potential prior to the incident. The facility's elopement risk screen conducted before the incident indicated the resident was not at risk for elopement, and there were no previous elopement attempts recorded. The facility's investigation revealed that the resident was able to exit the facility through a series of doors that did not have adequate security measures to prevent such an occurrence. The main entrance doors were accessible without a keypad lock, and there was no staff present in the main lobby area after 01:00 AM to monitor the resident's movements. The facility's failure to provide adequate supervision and secure the facility's exits allowed the resident to leave the premises unnoticed, placing her in immediate jeopardy.
Removal Plan
- A WanderGuard was placed on R1 with orders to monitor and document function each shift.
- R1's care plan was updated to include an intervention and monitoring for R1's WanderGuard.
- Staff completed an updated Elopement screening on R1 to reflect R1's new risk and behavior.
- The facility contacted maintenance and the facility door contractor to inspect the unit door's locking systems to ensure there was no other point of failure.
- The facility ordered parts to have a set of double doors coded with a keypad lock to prevent future elopements through those doors.
- Administrative Nurse D was in the process of providing education for all staff related to elopement, wandering, and missing residents.
Failure to Follow Sanitary Dietary Standards
Penalty
Summary
The facility failed to follow sanitary dietary standards related to cleaning, food storage, equipment storage, and food preparation practices. During an initial tour, it was observed that bowls were stored upright instead of inverted, and temperature logs for refrigerators, freezers, and the dishwasher lacked evidence of being checked on specific dates. Additionally, the walk-in freezer had uncovered and undated breaded chicken breasts, and open containers of cottage cheese and milk were not dated. A commercial meat slicer was found uncovered but not in use. These observations indicate a lack of adherence to proper food storage and equipment maintenance protocols, which are essential for preventing foodborne illnesses and ensuring food safety for residents. Further observations revealed that a dietary staff member did not perform hand hygiene before beginning food preparation and handled food and utensils with contaminated gloves. The staff member touched unclean surfaces and then directly handled food without changing gloves or performing hand hygiene. This practice continued as the staff member doffed gloves and proceeded to clean surfaces without washing hands, and later used an ungloved hand to grab a spatula by the end that touches food. Interviews with dietary staff confirmed that these actions were against the facility's policies, which require hand hygiene and proper use of gloves to prevent cross-contamination and foodborne illnesses. The facility's policies on hand hygiene and food storage were not followed, placing residents at risk of food safety concerns.
Failure to Secure Medication Room and Label Insulin Pens
Penalty
Summary
The facility failed to store medications and biologicals appropriately when the medication room on the second floor was found unlocked during an inspection. The room contained a secured digital medication storage system, a locked medication refrigerator, and a shelf with unsecured over-the-counter medications. Licensed Nurse J secured the room upon completion of the inspection. Additionally, an inspection of a medication cart revealed that a resident's insulin pens were not labeled with the open date, which is required to ensure proper usage and disposal within 28 days. Licensed Nurse G immediately removed the unlabeled insulin pens from the cart. Licensed Nurse J stated that staff were expected to ensure the medication room door was fully shut and locked at all times to prevent resident access to medications and nursing equipment. Administrative Nurse D confirmed that the medication rooms were expected to be locked at all times and that insulin pens should be labeled with the open date and stored in the medication carts. The facility's Medication Storage policy indicated that all medications and biologicals should be stored safely following the manufacturer's storage recommendations and properly labeled with the recommended expiration dates.
Inadequate Infection Control Standards
Penalty
Summary
The facility failed to ensure adequate infection control standards related to enhanced barrier precautions, wearing personal protective equipment (PPE), and indwelling catheter maintenance. During inspections, it was observed that several residents' rooms lacked the necessary signage and PPE for enhanced barrier precautions. Specifically, rooms of residents with wound care and indwelling urinary catheters did not have the required signage or PPE posted. Additionally, a certified nurse aide entered a resident's room with a bacterial urinary infection and performed peri-care without donning the required PPE, despite the presence of a contact isolation sign and PPE outside the room. Further observations revealed that a resident's urinary catheter bag was improperly placed on the floor, which is against the facility's infection control policy. Interviews with staff confirmed that they were aware of the requirements for enhanced barrier precautions and PPE usage, as they had recently undergone training on these topics. However, the staff failed to consistently implement these precautions, placing residents at risk for infectious diseases. The facility's policies on infection control and catheter care were not adequately followed, leading to these deficiencies.
Failure to Honor Resident Requests and Maintain Dignity
Penalty
Summary
The facility failed to honor a resident's request during dining and maintain another resident's dignity during care in a common area. One resident repeatedly asked to be moved to the TV room during breakfast, but staff ignored his requests and did not assist him, even though his wheelchair was locked and he could not move himself. The resident expressed frustration and was visibly distressed, coughing and spitting out food without receiving timely assistance from the staff. Eventually, a social services staff member moved him to the TV room after he had been ignored for an extended period. Another resident, who had severe cognitive impairment and required substantial assistance with transfers, was exposed during transfers in the common area. The licensed nurse used a gait belt to lift the resident, causing her shirt to rise and expose her skin from the waist to the breast area. This occurred on multiple occasions, and the staff acknowledged that the resident should not have been exposed in a common area. The facility's policy on resident rights and dignity was not followed, leading to the resident's exposure and potential negative psychosocial outcomes. The facility's policy emphasized the importance of treating residents with respect and dignity, ensuring their rights to a dignified existence and self-determination. However, the staff's actions and inactions in these instances did not align with the policy, resulting in deficiencies that compromised the residents' dignity and self-worth.
Failure to Provide Necessary Assistive Services for Transfers
Penalty
Summary
The facility failed to ensure that Resident 46 received the necessary assistive services for transfers, which placed the resident at risk for loss of independence, decreased self-esteem, and impaired dignity. Resident 46 had a history of cerebral infarction, dementia, and depression, and was documented to have severely impaired cognition. The resident's care plan indicated the use of a pivot disc and walker for transfers. However, observations on multiple occasions showed that staff did not use these assistive devices during transfers, instead using a gait belt that exposed the resident's skin and did not provide adequate support for weight-bearing. Interviews with staff revealed inconsistencies in their knowledge and application of the resident's care plan. Certified Nurse Aide M and Licensed Nurse G both indicated that the resident was transferred with a gait belt and one staff person, but were unsure about the use of a pivot disc and walker. Administrative Nurse D confirmed that staff should follow the care guide, which is based on the care plan, and that any changes in a resident's status should be reported for re-evaluation. The facility's policy on Resident Rights and Responsibilities emphasized the importance of treating residents with dignity and providing person-centered care, which was not upheld in this case.
Failure to Implement Pressure-Reducing Interventions and Complete Weekly Wound Assessments
Penalty
Summary
The facility failed to ensure that a resident's pressure-reducing interventions were implemented correctly. Specifically, the low air-loss mattress pump for a resident with severe cognitive impairment and a Stage 3 pressure ulcer was set at an inaccurate weight of 280 lbs, despite the resident weighing only 107 lbs. This discrepancy was observed over multiple days, and staff interviews confirmed that the mattress should have been set to 120 lbs according to the resident's current weight. The facility's policy required staff to check the bed function and settings each shift, but this was not adhered to, placing the resident at risk for complications related to skin breakdown and pressure ulcers. The facility also failed to complete weekly wound assessments for another resident with a history of cerebral infarction, early onset Alzheimer's disease, and hemiplegia. This resident had a Stage 2 pressure ulcer and was at moderate risk for pressure ulcer development. The resident's electronic medical record lacked evidence of weekly wound assessments over several weeks, with gaps of 14 and 34 days between documented assessments. Staff interviews revealed that the unit charge nurse and wound care nurse were responsible for weekly skin checks and wound assessments, but these were not consistently performed or documented. The facility's policies on skin integrity and pressure ulcer prevention required weekly skin evaluations by a licensed nurse and the implementation of wound treatment orders when pressure ulcers were present. However, these policies were not followed, resulting in missed assessments and inadequate monitoring of the resident's pressure injuries. This failure placed the resident at risk for further complications related to skin breakdown and pressure ulcers.
Failure to Properly Manage Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment for a resident with an indwelling catheter by allowing the catheter drainage bag to rest on the floor. The resident, who had diagnoses of bladder cancer, dementia, and urinary retention, had a history of frequent urinary tract infections (UTIs) and required assistance from staff for proper hygiene related to the care of his indwelling catheter. Observations revealed that the catheter bag contained dark amber urine and was placed directly on the floor at the foot of the resident's bed. Interviews with staff confirmed that the catheter drainage bag should never be placed on the floor and should be stored in a dignity bag attached to the bed to prevent infections. The resident's medical records documented multiple physician orders for antibiotics to treat recurrent UTIs, indicating a history of infection complications. Despite the facility's policy on catheter care, which mandates that catheter care be performed appropriately by qualified nursing staff to prevent complications, the facility failed to adhere to this policy. This deficiency placed the resident at risk for further catheter-related complications and UTIs, as evidenced by the improper placement of the catheter drainage bag on the floor.
Improper Storage of CPAP Mask
Penalty
Summary
The facility failed to ensure the proper storage of a resident's CPAP mask, which was observed to be laid directly on the bedside table without containment on multiple occasions. The resident, who had a history of obstructive sleep apnea and other medical conditions, was dependent on staff for all activities of daily living and had moderately impaired cognition. Despite physician orders to apply the CPAP at bedtime and remove it in the morning, the staff consistently placed the mask on the bedside table without using a sanitary storage method. Interviews with staff revealed a lack of adherence to the facility's policy on CPAP mask storage. A Certified Nurse's Aide stated that the mask was always placed on the bedside table, while a Licensed Nurse and an Administrative Nurse confirmed that the mask should be stored in a dated plastic bag. The facility's Oxygen Therapy policy also required that the device be stored in a plastic or other bag when not in use. The failure to follow these guidelines placed the resident at an increased risk for respiratory infection and complications.
Failure to Identify Risks Associated with Bed Rail Assessment
Penalty
Summary
The facility failed to identify a resident's low air-loss mattress and bolstered overlay as potential risks in the side rail assessment. The resident, who had severe cognitive impairment, Alzheimer's disease, major depressive disorder, a stage 3 pressure ulcer, and a history of falls, was using a low air-loss mattress and bolstered overlay provided by hospice services. Despite these devices being in place, the facility's assessment did not account for the specific risks associated with the mattress and overlay, which could lead to gaps between the rail and bed, possible strangulation hazards, and the effectiveness of the assist rails. Observations and interviews revealed that the facility's staff, including the licensed nurse and administrative nurse, were unsure if the risk assessments differentiated between mattress types and overlays. The facility's policy required continual assessment of assistive devices attached to beds to ensure safety, but the assessment for this resident did not identify the low air-loss mattress or bolstered overlay as risks. This oversight placed the resident at risk for inadequate care due to unidentified care needs.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
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Nursing homes near Olathe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Villa St Francis Catholic Care Center Inc | 1.1 mi | ★★★★★ | 0 | 0 |
| The Plaza Health Services At Santa Marta | 2.4 mi | ★★★★★ | 13 | 0 |
| Nottingham Health And Rehabilitation | 3 mi | ★★★★★ | 10 | 0 |
| Azria Health Olathe | 3.5 mi | ★★★★★ | 28 | 1 |
| Stratford Commons Rehab & Health Care Center | 3.6 mi | ★★★★★ | 21 | 1 |
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