Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Azria Health Olathe during CMS and state inspections, most recent first.
Failure to Prevent Resident-on-Resident Sexual Abuse: A resident with severe dementia and a history of inappropriate touching repeatedly displayed sexual behaviors toward others, including staff and residents, without effective interventions being implemented after an earlier hospital evaluation for inappropriate behavior. The resident later touched another cognitively impaired resident in her genital area against her wishes, and staff separated the residents after the incident.
The facility failed to accurately reconcile controlled drugs at shift change and maintain narcotic count sheets. Review of the 200 hall narcotic shift count sheet showed missing signatures for both the oncoming and off-going nurse across multiple shifts, and staff interviews confirmed that controlled substances were expected to be counted together at each shift change. The facility policy required controlled meds to be counted at the end of each shift by both nurses, with any discrepancies documented and reported to the DON.
Unsanitary food storage and kitchen conditions: The kitchen floor was heavily dirty with old food debris and trash in the food prep and stove area, and a soiled towel was found on the floor near the stove. Dirty floors and a soiled Band-Aid were observed in the dry storage room, a dented can was on the canned storage rack, and packaged turkey cold cuts were stored under the walk-in air blower with liquid dripping onto them from a pipe. Dietary staff stated food was not to be placed there and that staff were expected to clean after every meal service.
CNA In-Service Training Not Completed: Five sampled CNAs did not complete the required 12 hours of annual in-service education. Staff interviews showed monthly meetings occurred, but CNA and LN staff could not recall the last dementia care in-service, while abuse and neglect in-services were said to occur often. The HR department and administrative staff were identified as responsible for ensuring direct care staff received required in-services, and the facility policy required initial orientation and annual in-service training.
Failure to use wheelchair foot pedals during resident transport. Several residents, including severely cognitively impaired residents on the secured unit, were observed being pushed in wheelchairs without foot pedals, with their feet sliding on or touching the floor. A CNA stated foot pedals were to be used on all residents when being pushed, and an Administrative Nurse confirmed staff were expected to use them; the facility could not provide a related policy.
Unsecured oxygen storage and failure to follow NPO order: Oxygen storage rooms were observed unlocked with full cylinders and E-tanks inside, and staff reported the rooms should have been locked. The facility also did not follow an NPO order for a resident with severe cognitive impairment, cerebral palsy, dysphagia, and tube feeding needs; the resident was observed with crushed/chunked ice in a cup without nursing monitoring for aspiration, and staff gave conflicting statements about the ice-chip allowance.
Unlocked Medication Cart Left Unattended: A nurse's medication cart on the 200 hall was observed unlocked and unattended while it contained two insulin pens and two vials of insulin. An LN stated she had stepped away briefly to assist another nurse, and an Administrative Nurse stated carts should never be left unlocked when staff are away from them. The facility policy required medication carts to be secured during med passes and locked whenever out of staff view.
A resident with severe cognitive impairment waited while other residents ate before receiving her meal, and she was transported to the dining room in a wheelchair without foot pedals as her feet slid on the floor. Another resident with anxiety and major depressive disorder was involved in a dining room altercation when dietary staff became verbally aggressive after he asked for milk, yelled at him, and got in his face until a CNA intervened; the resident later said he felt threatened, humiliated, and dehumanized.
Failure to provide transfer notification and discharge summary: The facility did not ensure that a resident and representative received written transfer notification when the resident was sent to the hospital, and it also did not complete a discharge summary with a recapitulation of stay for another resident discharged home. The records showed one resident with COPD, CHF, HTN, depression, and anxiety, and another resident with TBI, insomnia, and hemiplegia, with documented cognitive and functional needs.
A resident with Guillain-Barre syndrome, a fractured toe, fibromyalgia, and DM did not have a person-centered baseline care plan that addressed chronic pain. The care plan only noted medication administration and lacked direction for pain related to her diagnoses, while the resident stated she had to wait for pain medication after admission and that her chronic pain was horrible at times.
Pressure Ulcer Prevention Failures: The facility failed to ensure a resident with paraplegia, DM, and an existing stage 3 pressure ulcer had a low-air-loss mattress set to the correct weight, and failed to ensure another resident with quadriplegia, DM, and pressure ulcers had heels offloaded with boots or pillows while in bed. Observations showed the mattress remained set at 550 lbs for a resident weighing 213.6 lbs, and the other resident’s heels were left directly on the mattress, with no nursing documentation that heel floating was offered or refused.
Failure to Address Left-Hand Contracture Care: A resident with contractures, CVA, and dementia was observed with the left elbow bent and the left hand tightly closed without a splint or other device in place. The EMR lacked a re-evaluation of the current contractures, lacked documentation of alternative interventions, and lacked documentation of splint refusals. Staff stated therapy evaluated residents with contractures, nursing applied and monitored splints, and refusals were to be documented on the TAR and referred back to therapy.
Missing Dialysis Order and Incomplete Care Plan: A resident with ESRD requiring dialysis had no dialysis physician order entered in the EMR, and the care plan incorrectly directed staff that he received hemodialysis while lacking key dialysis details such as treatment days, clinic location, contact information, and communication instructions. The resident also had osteomyelitis, COPD, and hemiplegia, with significant mobility and ADL assistance needs.
Failure to Address PTSD Triggers in Care Planning: The facility failed to identify trauma-based triggers and implement individualized interventions for a resident with PTSD, despite documentation of PTSD, bipolar disorder, CHF, and other diagnoses. The resident’s CAA did not address PTSD, and the care plan only addressed adjustment issues and communication, without guidance on triggers or interventions to prevent re-traumatization. An LN and an administrative nurse both acknowledged uncertainty about whether PTSD was addressed in the resident’s plan of care.
Failure to Provide Consistent Dementia-Related Behavioral Interventions: A resident with dementia and severe cognitive impairment had repeated inappropriate touching and sexually inappropriate behaviors on a secured unit. The care plan addressed cueing, supervision, and simple activities, but lacked specific interventions for boundary concerns until after multiple incidents. Nursing notes and staff interviews showed ongoing redirection, escalating behaviors, and uncertainty about what interventions were actually in place.
A resident with DM, quadriplegia, and other chronic conditions had an order for Humalog Mix 75/25 with meals, to be held if blood glucose was under 200 mg/dl. The TAR showed multiple blood glucose readings below that threshold, but there was no evidence the insulin was held as ordered. Staff interviews indicated nurses were expected to double-check the TAR and give meal-time insulin when the meal arrived or while the resident was eating.
Hospice care plans were not fully coordinated for two residents. One resident had severe cognitive impairment, total dependence for several ADLs, and hospice services, but staff were unsure what hospice provided and relied on the hospice binder for details. Another resident with lung cancer, COPD, and hemiplegia/paresis had a hospice care plan that lacked the hospice provider’s contact information and did not identify supplies, DME, medications, or hospice visit frequency, despite staff expecting those details to be included.
Failure to Prevent Resident-on-Resident Sexual Abuse
Penalty
Summary
The facility failed to keep a cognitively impaired resident free from sexual abuse when a resident with severe dementia and a documented history of inappropriate touching repeatedly engaged in sexually inappropriate behavior toward others and was not given effective interventions before the incident with another resident. The resident had a BIMS score of 3, used a wheelchair, and had care plan and behavioral assessment documentation noting cognitive impairment, aggressive behaviors, and later inappropriate touching. Progress notes showed he was observed holding hands, making affectionate gestures, repeatedly touching other residents, and becoming aggressive when redirected. After an earlier episode in which he was observed touching a resident in a sexual way and was sent to the hospital for evaluation of inappropriate behavior, he returned to the facility, but the record did not show that new interventions were implemented to address the ongoing behaviors. Later, staff again observed sexual behaviors toward staff, and the resident continued to display inappropriate touching on the unit. The facility’s records and staff statements indicated that his behaviors had been ongoing and that he required close supervision and repeated redirection. The deficiency occurred when the resident placed his hands between another cognitively impaired resident’s thighs and touched her genital area against her wishes. The female resident screamed for him to stop, and staff separated the residents and placed the male resident under one-to-one supervision until he transferred out of the facility. The female resident was unable to recall the incident, and staff documented that both residents were assessed after the event.
Incomplete Controlled Drug Shift Counts
Penalty
Summary
The facility failed to ensure an accurate reconciliation of controlled drugs at the end of daily work shifts and failed to maintain staff count sheets for controlled drugs. The facility had a census of 107 residents, and the sample included 26 residents, with five medication carts and three medication rooms. On review of the September 2025 Narcotic Shift Count Sheet for the 200 hall from 09/01/25 through 09/09/25, surveyors found a missing signature from either the on-coming nurse or the off-going nurse on each of those nine dates. During interview, LN K stated that narcotics should be counted at shift change with both the oncoming and off-going nurse, and Administrative Nurse D stated that she expected the narcotics to be counted between the oncoming nurse and the off-going nurse. The facility's Controlled Substances policy stated that controlled medications were to be counted at the end of each shift by the nurse coming on duty and the nurse going off duty, with discrepancies documented and reported to the DON.
Unsanitary food storage and kitchen conditions
Penalty
Summary
The facility failed to follow sanitary dietary standards related to food storage, preparation, and meal service for a census of 107 residents with one kitchen and two dining rooms. During a walkthrough of the kitchen on 09/08/25 at 07:05 AM, the main kitchen floor was observed to be heavily dirty with old food debris and trash in the food prep and stove area, and a soiled towel was on the floor next to the stove top ovens. Dessert saucers and plates were stored upside down in the dishware storage rack. In the dry food storage area, the floors were dirty and a soiled Band-Aid was found in the center of the room floor. A dented 6.56-pound can of fruit cocktail was also observed on the canned storage rack. In the walk-in refrigerator, a metal tray containing five packaged turkey cold cut meats was stored underneath the air blower. The tray had liquid dripping onto the turkey packages and pooling in the tray from a pipe coming from the air conditioner. On 09/11/25 at 12:01 PM, Dietary Staff BB stated that food was not to be placed underneath the air conditioner in the walk-in units and that the food was moved and thrown out. He also stated that staff were expected to clean after every meal service. The facility's Food Services and Nutrition policy, dated 10/2017, stated that the facility would promote proper service, cleaning, and food storage, that surfaces in the dining room and kitchen were to be cleaned and sanitized per professional standards, and that food was to be labeled, dated, and stored safely to prevent cross-contamination and food-borne illness.
CNA In-Service Training Not Completed
Penalty
Summary
The facility failed to ensure that five of five sampled CNAs had completed the required 12 hours of in-service education within the past 12 months. Record review showed that CNA MM, hired on 06/26/24; CNA NN, hired on 09/29/24; CNA OO, hired on 09/22/22; CNA PP, hired on 11/22/23; and CNA QQ, hired on 10/25/23 had not completed the required in-services in the past 12 months. The facility had a census of 107 residents at the time of the survey. During interviews, CNA O stated the facility did have monthly meetings but could not remember the last time she had a dementia in-service. LN K stated the facility did provide monthly in-services and could not remember the last dementia care in-service, while also stating abuse and neglect in-services were provided often. Administrative Nurse D stated the human resource department and administrative staff were responsible for ensuring direct care staff received the required 12 hours of in-services. The facility's In-Service Training, All Staff policy, last revised 08/2022, stated all staff must participate in initial orientation and annual in-service training.
Failure to Use Wheelchair Foot Pedals During Resident Transport
Penalty
Summary
The facility failed to reasonably accommodate residents' needs and preferences by not using foot pedals during wheelchair transports for R37, R43, R104, and R122. R37, R43, and R104 were severely cognitively impaired residents on the secured unit, and each was observed being pushed in a wheelchair without foot pedals while being transported to the dining room area or dining room table, with their feet sliding on or touching the floor. R122 was observed being wheeled from the main dining hall to her room without foot pedals, and her feet slid on the ground as staff pushed her. A CNA stated that foot pedals were to be used on all residents when being pushed in wheelchairs and that all wheelchairs had foot pedals available, and she stated that pushing residents without them could cause an injury or fall. An Administrative Nurse also stated that staff were expected to use foot pedals while pushing residents' wheelchairs, and the facility was unable to provide a policy related to assistive devices or accidents.
Unsecured oxygen storage and failure to follow NPO order
Penalty
Summary
The facility failed to ensure oxygen tanks were stored in a securely locked room. During the initial tour, the oxygen storage room on the 200 hall was unlocked with 21 unused full oxygen cylinders present, and the oxygen storage room on the 100 hall was unsecured with 32 oxygen E-tanks stored in the room. A return check later the same morning found the 200-hall oxygen storage room still unlocked. A CNA stated the room should be locked but the lock was broken and had been broken for the past two years, while an LN stated the code for the room had recently been changed and that the room should be locked all the time. An administrative nurse stated the oxygen storage rooms should always be locked unless a staff member was replacing a used tank with a new one. The facility did not have a policy regarding oxygen storage or accidents. The facility also failed to follow R28’s NPO physician’s order. R28’s EMR documented diagnoses including cerebral palsy, protein-calorie malnutrition, urinary retention, impulse disorder, legal blindness, need for assistance with personal cares, and dysphagia. The admission MDS recorded a BIMS score of zero and dependence on staff for all ADLs. R28’s care plan and CAA documented tube feeding, NPO status, and staff supervision for intake, with ice chips allowed as requested. However, the EMR order dated 06/12/25 documented NPO diet, and on two separate observations R28 was seen in a Broda chair with a cup of crushed or chunked ice and a spoon, with no nursing staff monitoring him for aspiration. Staff interviews reflected differing understanding of whether and how often R28 could have ice chips, and the administrative nurse stated there should be an order for ice chips or documentation that he was safe to have them. The facility did not provide an accident policy.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure a medication cart was kept locked and secured while staff were away from it on the 200 hall. During observation on 09/08/25 at 07:14 AM, the nurse's medication cart was left unlocked and unattended by staff, and it contained two insulin pens and two vials of insulin. The facility had three medication rooms and five medication carts, and the census was 107 residents. At 07:18 AM, an LN stated she had stepped away from the cart briefly to assist another nurse, but the cart should always be locked when she was away from it. On 09/10/25 at 01:22 PM, an Administrative Nurse stated that medication carts should not ever be left unlocked when staff are away from the cart. The facility's Security of Medication Cart policy, dated January 2023, stated that the medication cart shall be secured during medication passes, must be locked before the nurse enters the resident's room, and must be securely locked at all times when out of the nurse's view.
Failure to Maintain Resident Dignity During Meal Service and Staff Interaction
Penalty
Summary
The facility failed to provide a dignified care environment for two residents. One resident had diagnoses including dementia, muscle weakness, repeated falls, and need for assistance with personal care, and her MDS showed severe cognitive impairment with a BIMS score of zero. Her care plan directed staff to provide a consistent routine, anticipate her needs, and involve her in decision-making, but during breakfast she was wheeled to the dining room without foot pedals on her wheelchair, her feet slid on the floor, and she repeatedly told staff she was hungry while other residents were served and ate before she received her meal. During the meal service, staff served trays two at a time from the kitchen because the dishwasher had been broken and meals were being served on Styrofoam plates. The resident remained seated while other residents at nearby tables received and ate their food, and she did not receive her meal until after most of the dining room had already been served. Staff stated meals were supposed to be served around the same time so residents could enjoy them together, and that residents should not be made to wait while others ate. A second resident had diagnoses including anxiety disorder, cognitive communication disorder, major depressive disorder, and need for assistance with personal cares. Although his MDS showed intact cognition and independence with many ADLs, his care plan identified psychosocial risk related to anxiety and directed staff to move him to a calmer environment during conflict. A facility incident report and witness statements documented an altercation in the dining area in which dietary staff became verbally aggressive after the resident asked for milk, yelled at him, and approached him closely until another CNA intervened and directed the staff member to leave. The resident later stated he felt threatened, humiliated, and dehumanized by the interaction.
Failure to Provide Transfer Notification and Discharge Summary
Penalty
Summary
The facility failed to ensure that Resident 1 and the resident’s representative were provided, as soon as practicable, a written notification of transfer when Resident 1 was transferred to the hospital. Resident 1’s record documented diagnoses of COPD, CHF, HTN, major depressive disorder, and anxiety. The resident’s MDS records showed multiple unplanned hospital transfers with anticipated return to the facility, and the annual MDS documented a BIMS score of 15, indicating intact cognition. The record also showed that Resident 1 required substantial assistance and was dependent on staff for care, with the overall goal to remain in the facility and no active discharge planning occurring. The care plan directed staff to encourage the resident to express concerns and feelings and to meet all spiritual needs. The facility also failed to ensure that Resident 120 had a discharge summary and recapitulation of the stay completed when the resident was discharged home. Resident 120’s record documented diagnoses of TBI, insomnia, and hemiplegia. The admission MDS documented a BIMS score of 12, indicating moderately impaired cognition, and showed the resident was independent with bed mobility and toileting but needed partial to moderate assistance with dressing. The care area assessment documented that Resident 120 required staff assistance with ADLs, and the care plan stated the resident required staff supervision during bathing. The nursing note documented discharge home with personal belongings, but the facility was unable to provide a discharge summary, including a recapitulation of the stay, a final summary of the resident’s status, and reconciliation of pre- and post-discharge medications.
Baseline care plan omitted chronic pain needs
Penalty
Summary
The facility failed to develop a person-centered baseline care plan for R121 that included her chronic pain within the required timeframe after admission. R121’s EMR documented diagnoses of Guillain-Barre syndrome, a fractured toe, fibromyalgia, and diabetes mellitus. Her admission MDS and CAA were in progress, and her baseline care plan dated 09/05/25 stated only that nursing staff would administer all medication as ordered by the physician. The care plan did not include direction for her chronic pain related to the fractured toe, Guillain-Barre syndrome, or fibromyalgia, and the e-signed baseline care plan in the EMR also lacked documentation related to chronic pain. During observation on 09/10/25, R121 was seated in her electric wheelchair at the dining room table and stated she had to wait for her pain medication after she was admitted to the facility. She said her chronic pain was horrible at times. Staff interviews reflected that resident care information should be available on the care plan or Kardex, that chronic pain should be included in the baseline care plan, and that the baseline care plan was expected to be completed within 24 hours of admission. The facility policy stated the baseline care plan was to meet the resident’s immediate health and safety needs and be developed within 48 hours of admission.
Pressure Ulcer Prevention Failures
Penalty
Summary
The facility failed to ensure a resident with paraplegia, diabetes mellitus, and an existing stage 3 pressure ulcer had a low-air-loss mattress set at the correct weight setting. The resident’s record documented a pressure-reducing device on the bed and a care plan that included a low-air-loss mattress and staff monitoring for proper functioning, but the care plan did not include direction for staff to monitor the mattress setting. On 09/08/25 and 09/09/25, the resident was observed lying in bed while the low-air-loss mattress remained set at 550 pounds, and the resident’s documented weight was 213.6 pounds. The record also showed the resident had multiple wounds and was assessed as being at moderate risk for pressure ulcers with a Braden score of 14. Staff interviews indicated CNA staff did not adjust the low-air-loss mattress and believed it was set up by supply personnel, while an LN stated the mattress should be set close to the resident’s weight and that there was no place on the TAR to document verification of the setting. Administrative nursing staff stated the mattresses were rented, were set by medical supply and maintenance, and that they were unsure who monitored the mattress daily. The facility also failed to ensure another resident with quadriplegia, diabetes mellitus, and existing pressure ulcers had offloading boots applied to the heels to prevent pressure ulcers. The resident’s care plan directed staff to offload bilateral heels using pillows or soft heel lift boots when in bed, as tolerated, and the resident was assessed as high risk for pressure ulcers with a Braden score of 13. However, nursing progress notes lacked documentation that the resident was offered heel floating or refused it, and observations showed the resident’s heels lying directly on the mattress on two occasions. Staff interviews indicated that heel floating or offloading would be communicated through nursing documentation such as the TAR, Kardex, and care plan, but the observed care was not documented as provided.
Failure to Address Left-Hand Contracture Care
Penalty
Summary
The facility failed to ensure Resident 44 was provided services and treatment to prevent worsening of contractures in the left hand. Resident 44 had diagnoses including contracture of the left elbow, contracture of the left hand, depression, CVA, and dementia. The Annual and Quarterly MDS assessments documented moderately impaired cognition, bilateral lower ROM limitation, limited ROM in one upper extremity, dependence on staff for multiple ADLs, and no nursing restorative program. The care plan documented that nursing staff would administer medications as ordered, notify the nurse of decreased ROM, redness, pressure areas, or increased pain, and assist with proper body positioning in bed and wheelchair. A prior care plan also documented that Resident 44 refused a left resting splint. The EMR lacked documentation of a re-evaluation of the current left hand and left elbow contractures and lacked documentation of alternative interventions or services provided to prevent worsening of the contractures. The EMR also lacked documentation of refusals to wear the left-hand splint. During observations, Resident 44 was seen lying in bed with the left elbow bent against the abdomen and the left hand closed, with no splint or device in place to prevent worsening of the contractures. Staff interviews indicated therapy evaluated residents with contractures, nursing staff were expected to apply and monitor splints, refusals were to be documented on the TAR, and residents who refused splints were to be referred back to therapy for re-evaluation.
Missing Dialysis Order and Incomplete Care Plan
Penalty
Summary
The facility failed to ensure that a resident with ESRD who required peritoneal dialysis had a dialysis physician order entered into the EMR. The resident also had diagnoses of osteomyelitis, COPD, and hemiplegia, and his admission MDS documented a BIMS score of 13 with intact cognition. He used a walker and wheelchair, had functional limitations in both upper and lower extremities, and required substantial assistance to total dependence for functional abilities. His Functional Abilities CAA documented that he needed assistance with ADLs and mobility. The resident’s care plan, revised after admission, directed staff that he received hemodialysis and included instructions to check and change the dressing daily at the left upper arm access site and not to draw blood or take blood pressure in the left arm. However, the care plan lacked direction on his dialysis days, the location and contact information of the dialysis clinic, and how information would be communicated between the facility and the dialysis clinic. The EMR also lacked a physician order for dialysis. Staff stated that the admitting nurse was responsible for entering orders into the EMR and that the unit manager should have verified the order was entered correctly. Administrative nursing staff stated the dialysis order should have been entered at admission and that the care plan should reflect the dialysis schedule, clinic name, and special instructions.
Failure to Address PTSD Triggers in Care Planning
Penalty
Summary
The facility failed to assess and identify trauma-based triggers related to R11’s PTSD and failed to implement individualized interventions to prevent re-traumatization. R11’s EMR documented diagnoses of PTSD, CHF, bipolar disorder, and hydronephrosis. Her annual MDS dated 03/20/25 documented a BIMS score of 15, indicating intact cognition, and that she required only supervision from staff for her cares. She also had an active diagnosis of PTSD, and her Psychotropic Drug Use CAA dated 03/02/25 documented psychotropic medication use to manage psychiatric illness or condition, with monitoring and medication review processes in place. However, the CAAs did not address her PTSD. R11’s care plan, revised on 08/05/25, addressed adjustment issues related to recent losses and changes and directed staff to allow her to communicate her feelings and encourage daily conversations with staff and other residents, but it did not include direction on PTSD triggers or interventions to prevent re-traumatization. During interviews, LN K stated he knew some residents’ care plans addressed PTSD but was not certain R11’s did, and said staff should be made aware of past trauma and possible triggers. Administrative Nurse D stated social services completed an initial evaluation at admission and quarterly, but she could not say whether PTSD was addressed, and she expected R11’s care plan to address past traumas and interventions to prevent re-traumatization.
Failure to Provide Consistent Dementia-Related Behavioral Interventions
Penalty
Summary
The facility failed to provide consistent dementia-related behavioral interventions for a resident with dementia, severe cognitive impairment, repeated falls, muscle weakness, and a need for substantial to maximal assistance with personal care and mobility. The resident’s care plan identified cognitive impairment, need for cueing and supervision, and a secured unit placement due to medical diagnoses and elopement risk. The plan also directed staff to engage the resident in simple activities, keep his routine consistent, and later noted that he was dependent on staff for emotional, intellectual, physical, and social needs. The resident’s record documented escalating inappropriate touching and sexually inappropriate behaviors on the secured unit. Nursing notes described the resident holding hands with other residents, repeatedly touching other residents, and touching a resident in a sexual way, with staff providing redirection and removing him from the area. After one incident, the resident became aggressive when redirected and was moved to his room before being sent to an acute medical facility for evaluation. The acute care summary noted concerns of worsening promiscuity and combativeness, and the resident later returned to the facility. The care plan was not updated with interventions for inappropriate touching or boundary concerns until after the resident had multiple documented incidents. Prior to that update, the plan lacked interventions related to his inappropriate touching or boundary concerns. Later documentation showed the resident continued to touch others, including an incident in which he placed his hands between another severely cognitively impaired resident’s inner thighs, causing the other resident to scream for him to stop. Staff separated the residents, assessed them, and placed the resident on one-to-one supervision, while staff interviews indicated ongoing sexual impulses and uncertainty about what specific interventions were in place for his behaviors.
Insulin Not Given Per Meal-Time Parameters
Penalty
Summary
The facility failed to ensure that Resident 25’s insulin was administered before meals according to the physician-ordered parameters tied to blood glucose monitoring. Resident 25’s record documented diagnoses including diabetes mellitus, hypertension, quadriplegia, a left tibia fracture, muscle weakness, depression, and anxiety. The admission MDS showed a BIMS score of 15, indicating intact cognition, and documented that the resident needed setup or cleanup for eating and oral hygiene, was dependent for toileting, and required substantial to maximal assistance for bathing. The care area assessment and care plan documented that staff would anticipate the resident’s needs, administer medications as prescribed, and give diabetes medication as ordered. Physician orders included Humalog Mix 75/25, 3 units subcutaneously with meals for diabetes, with instructions to hold if blood sugar was less than 200 mg/dl, along with insulin glargine at bedtime. The TAR showed multiple blood glucose readings below 200 mg/dl, but there was no evidence that the insulin was held as ordered. During interviews, an LN stated nurses should double-check the TAR before giving insulin and would wait until the resident had the meal tray or give insulin after the resident had eaten. An administrative nurse stated the facility needed better oversight of insulin administration and that insulin ordered with meals should be given when the meal arrived or while the resident was eating.
Hospice Care Plans Lacked Coordinated Service Details
Penalty
Summary
The facility failed to ensure a coordinated plan of care was developed and available for two residents receiving hospice services. For one resident, the record showed multiple diagnoses including hypertension, anemia, epilepsy, psychosis, dementia, schizoaffective disorder, bipolar disorder, repeated falls, muscle weakness, palliative care, and major depressive disorder. The MDS documented severely impaired cognition, dependence on staff for toileting, bathing, dressing, and eating, and receipt of hospice services. The resident’s care plan addressed comfort measures, ADL support, environmental comfort, family involvement, and cooperation with hospice, but the survey found the hospice communication binder was the primary source of hospice information rather than a coordinated facility care plan that clearly reflected hospice services. During observations and interviews, staff members gave inconsistent responses about hospice services and what information belonged in the facility care plan. A CNA stated she was unsure what hospice provided, and licensed nurses stated they were unsure what hospice provided and believed hospice details were kept in the hospice binder or at the nurse’s station. One nurse stated hospice aides and nurses were good at letting staff know what equipment and supplies they brought, while an administrative nurse stated she believed everything hospice provided should be on the care plan. The facility’s hospice policy stated residents receiving hospice services should have coordinated care plans that include the hospice plan of care and the facility’s care and services. For the second resident, the record documented lung cancer, COPD, and hemiplegia/paresis. The MDS showed intact cognition but substantial to total dependence for ADLs, and the resident was on hospice care. The care plan included comfort-focused interventions, ADL assistance, pain monitoring, and cooperation with the hospice team, but it lacked the hospice provider’s name and contact information and did not identify what hospice provided, including supplies, DME, medications, or hospice staff visit details. Staff interviews confirmed uncertainty about whether the care plan contained this information, and the administrative nurse stated the care plan should document the hospice provider, contact information, what hospice provided, and when hospice staff would visit.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 722 citations issued within 25 miles in the last 12 months — including the 20 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Olathe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Olathe | 0.9 mi | ★★★★★ | 10 | 0 |
| The Healthcare Resort Of Olathe | 1.1 mi | ★★★★★ | 0 | 0 |
| Hoeger House | 1.2 mi | ★★★★★ | 0 | 0 |
| Evergreen Community Of Johnson County | 3.1 mi | ★★★★★ | 2 | 0 |
| Villa St Francis Catholic Care Center Inc | 3.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Azria Health Olathe.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.