Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Colonial Village during CMS and state inspections, most recent first.
A resident with a history of insomnia, progressive supranuclear palsy, dementia, and dysphagia experienced significant unplanned weight loss due to the facility's failure to implement adequate nutritional interventions. Despite being at risk for nutritional impairment, the resident's weight decreased from 163.8 lbs. to 150 lbs. over a few months. The facility did not involve the RD or provide necessary supplements in a timely manner, leading to continued weight loss and risk of malnourishment.
The facility did not complete the required yearly performance evaluation for a CNA hired in June 2023, as revealed by a review of performance evaluation records. Administrative Nurse D confirmed the absence of the evaluation, which is required by the facility's policy to identify employee strengths and training needs. This oversight placed residents at risk for inadequate care.
The facility failed to follow sanitary dietary standards for food storage, risking food-borne illnesses. An inspection revealed undated and unlabeled food items in the kitchen and kitchenettes, including milk, whipping cream, a spinach and beef sandwich, dessert pastries, and an expired Arginaid drink. Dietary staff confirmed that all opened food products should be labeled and dated, and personal or undated items should not be stored in the kitchenettes.
The facility failed to follow infection control standards related to hand hygiene and disinfecting shared equipment. Observations showed CNAs and an LN not performing hand hygiene between glove changes and not disinfecting equipment between resident uses. Staff interviews confirmed the expectations for hand hygiene and equipment disinfection, which were not met, placing residents at risk for infectious diseases.
A resident with cognitive impairment and multiple medical conditions was transferred to a hospital without the facility providing the required written notification of transfer to the resident or their representative. The facility's records lacked documentation of this notification, and staff confirmed the absence of the necessary paperwork.
A facility failed to provide a bed hold notice to a resident with dysphagia, cognitive-communication disorder, dementia, and acute kidney failure when transferred to a hospital. The resident's medical record lacked evidence of the notice, and administrative staff confirmed the requirement but could not locate it. This oversight placed the resident at risk for impaired right to return to the same room.
Two residents at risk for pressure ulcers had their low air-loss mattresses set at incorrect weights, with one resident's mattress set significantly higher than her actual weight. Staff did not adjust the settings, and the care plan lacked guidance on appropriate settings. Additionally, a resident's heel protectors were not used, and proper hand hygiene was not followed during wound care, increasing the risk of skin breakdown.
A facility failed to ensure a resident had a physician-ordered indication for an indwelling catheter and did not provide adequate catheter care. The resident, with muscle weakness and hypertension, had a Foley catheter without a documented indication. During care, CNAs did not perform hand hygiene between glove changes, violating the facility's hand hygiene policy. This placed the resident at risk of catheter-related complications and UTIs.
A facility failed to ensure a resident's PRN psychotropic medication had a 14-day stop date or specified duration, as required. The resident, diagnosed with anxiety disorder and dementia, had multiple PRN Lorazepam orders without the necessary documentation. Staff interviews confirmed the expectation for a stop date, and the facility's policy required PRN psychotropic medications to be used for the shortest duration with proper documentation.
A facility failed to ensure collaboration with hospice services for a resident with severe cognitive impairment and Alzheimer's disease. The resident's care plan lacked documentation of hospice contact information, equipment, medications, and services, placing the resident at risk for delayed services. Staff confirmed that necessary hospice information was not integrated into the care plan, contrary to the facility's hospice policy.
Failure to Implement Nutritional Interventions for Resident
Penalty
Summary
The facility failed to provide adequate nutritional interventions for a resident, identified as R25, who experienced significant unplanned weight loss. R25, who had a medical history including insomnia, progressive supranuclear palsy, dementia, and dysphagia, was admitted with a weight of 163.8 lbs. and was noted to be at risk for nutritional impairment. Despite being on a regular diet with regular texture and thin liquids, R25 experienced a gradual weight loss, dropping to 150 lbs. within a few months, which was a 13.06% decrease from his usual body weight of 185-190 lbs. The facility's records indicated that R25's weight loss was not addressed with appropriate nutritional interventions. Although R25 was added to a supplemental nutrition program for weight gain, there was no evidence of nutritional supplements being administered until much later. The facility's care plan for R25 included monitoring for dysphagia and providing supplements, but these interventions were not effectively implemented. The resident's weight continued to decline, and it was noted that he had difficulties feeding himself and resisted assistance from staff and his representative. The facility's policy required that residents at risk for significant weight loss be care planned based on nutritional impairments, with interventions implemented to prevent further weight loss. However, the facility did not involve the Registered Dietician (RD) when initial weight loss was noted, and the necessary interventions were not put in place in a timely manner. This oversight resulted in R25's continued weight loss and placed him at risk for malnourishment-related complications.
Failure to Complete Yearly Performance Evaluation for CNA
Penalty
Summary
The facility failed to complete the required yearly performance evaluation for one of the five Certified Nurse Aides (CNAs) reviewed, specifically CNA O, who was hired on June 21, 2023. This deficiency was identified during a review of the facility's performance evaluation and in-service records, which revealed that CNA O had not received a yearly performance evaluation. Administrative Nurse D confirmed the absence of the required evaluation for CNA O, despite the facility's policy mandating annual performance reviews for all CNA staff. The policy is intended to identify employee strengths and goals and determine training needs. The lack of a performance evaluation for CNA O placed the residents at risk for inadequate care.
Failure to Follow Sanitary Dietary Standards
Penalty
Summary
The facility failed to adhere to sanitary dietary standards concerning food storage, which posed a risk of food-borne illnesses to residents. During an inspection of the facility's kitchen, surveyors found an open but undated half-gallon carton of milk and a carton of heavy whipping cream in the walk-in refrigerator. Additionally, in the back hall kitchenette, there was an unlabeled plate of spinach and beef sandwich and an undated bag with dessert pastries. The main dining kitchenette drink station contained an open and undated bottle of whipping cream, and the refrigerator held an eight-fluid-ounce container of Arginaid with an expired date. Dietary Staff BB confirmed that all opened food products should be labeled and dated, and personal or undated items should not be placed in the kitchenettes. The facility's Storage Guidelines policy, revised on a specific date, mandates that all food and supplies be stored appropriately to ensure quality and safety, which was not followed in this instance.
Infection Control Deficiency in Hand Hygiene and Equipment Disinfection
Penalty
Summary
The facility failed to adhere to proper infection control standards, specifically in hand hygiene and disinfecting shared equipment between residents. During an observation, two CNAs were seen transferring a resident using a mechanical lift without performing hand hygiene between glove changes. The CNAs also failed to disinfect the lift after use. Another observation revealed a licensed nurse performing wound care on a resident without adhering to hand hygiene protocols between glove changes, and using the same gloves to handle wound care supplies. Interviews with staff confirmed that hand hygiene should be performed between glove changes and when transitioning from dirty to clean tasks. It was also noted that shared equipment should be disinfected between each resident use. The facility's policies on hand hygiene and cleaning of resident-care equipment were not followed, as evidenced by the observations and staff interviews. These practices placed residents at risk for complications related to infectious diseases.
Failure to Provide Written Notification of Transfer
Penalty
Summary
The facility failed to provide written notification of transfer to a resident, identified as R32, and/or their representative, specifying the location and reason for the facility-initiated transfer. This deficiency was identified during a review of R32's records, which showed that the resident was sent to an acute care facility due to changes in mental status and returned to the facility two days later. However, the Electronic Medical Records (EMR) lacked documentation of the required written notification of transfer. R32's medical history included diagnoses of dysphagia, cognitive-communication disorder, dementia, and acute kidney failure. The resident's Discharge Minimum Data Set (MDS) indicated a discharge to a short-term hospital with an anticipated return, and upon return, the Entry MDS noted moderate cognitive impairment requiring substantial assistance for daily activities. Despite these documented needs, the facility did not provide a policy related to transfers and discharges, and Administrative Staff A confirmed the absence of the required written notification for R32's hospitalization.
Failure to Provide Bed Hold Notice for Hospitalized Resident
Penalty
Summary
The facility failed to provide a copy of the bed hold policy to a resident, identified as R32, and/or their representative when the resident was transferred to a hospital. The resident's medical records indicated diagnoses of dysphagia, cognitive-communication disorder, dementia, and acute kidney failure. The resident was discharged to a short-term hospital with an anticipated return to the facility, and subsequently returned from the hospital. However, the medical record lacked evidence of a bed hold notice being sent to the resident or their representative for the transfer. Upon review, the facility's administrative staff confirmed the requirement to send both a written notification of transfer and a bed hold notice, but they were unable to locate the notice for the resident's hospitalization. The facility's bed hold policy, revised in July 2024, mandates providing written notifications of bed hold and the facility's return policy to each resident or their representative. The failure to provide this notice placed the resident at risk for impaired right to return to the facility to the same room.
Inadequate Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure that pressure-reducing interventions were correctly implemented for two residents, R7 and R16, who were at risk for pressure ulcers. For R7, the low air-loss mattress was consistently set at an inappropriate weight of 500 to 550 pounds, despite R7 weighing only 111 pounds. This setting was not adjusted by the staff, as they only ensured the mattress was functioning, and the care plan lacked guidance on the appropriate settings for the mattress. The administrative nurse confirmed that the higher weight settings added more pressure to the resident's body, which could lead to skin breakdown. R16, who had a history of muscle weakness and hemiparesis, was also at risk for pressure ulcers. The low air-loss mattress for R16 was set at 300 pounds, which was not aligned with her actual weight of 197.6 pounds. Observations revealed that R16's heel protectors were not in use, and her heels were resting directly on the bed. Additionally, during wound care, the licensed nurse failed to perform proper hand hygiene between glove changes, potentially compromising the resident's skin integrity. The facility's policy required that pressure-reducing devices be set according to the resident's weight and care needs, but this was not adhered to. The facility's Prevention of Pressure Injuries policy outlined the need for appropriate interventions based on risk factors and care needs, including the correct setting of pressure redistribution surfaces. However, the facility did not ensure that the low air-loss mattresses were set correctly for R7 and R16, placing them at risk for complications related to skin breakdown and pressure ulcers. The staff's lack of adherence to the policy and failure to adjust the mattress settings contributed to the deficiency.
Inadequate Catheter Care and Lack of Physician Order Indication
Penalty
Summary
The facility failed to ensure that a resident had a physician-ordered indication for an indwelling catheter and did not provide adequate catheter care according to the standards of care. The resident, who had diagnoses of muscle weakness, need for assistance with personal care, and hypertension, had an intact cognition as indicated by a BIMS score of 14. The resident's care plan included specific instructions for catheter care, such as positioning the catheter drainage bag below the bladder level and monitoring for signs of discomfort during urination. However, the physician's order for the Foley catheter lacked an indication for its use. During an observation, two CNAs were seen providing catheter care to the resident. The CNAs failed to perform hand hygiene between glove changes, which is a critical step in preventing the spread of infections. The facility's hand hygiene policy emphasizes the importance of hand hygiene in preventing healthcare-associated infections. Interviews with the CNAs and nursing staff revealed that they were aware of the hand hygiene protocols, yet they did not adhere to them during the observed care. This failure to follow proper hand hygiene practices and the lack of a documented indication for the catheter placed the resident at risk of catheter-related complications and urinary tract infections.
Failure to Ensure PRN Psychotropic Medication Stop Date
Penalty
Summary
The facility failed to ensure that a resident's as-needed (PRN) psychotropic medication had a 14-day stop date or a specified duration with supporting physician documentation. This deficiency was identified during a review of the resident's electronic medical record, which revealed multiple PRN orders for Lorazepam without the required stop date or specified duration. The orders were for Lorazepam oral concentrate and tablets to be administered for moderate insomnia, moderate anxiety, and severe agitation, all dated the same day, but lacking the necessary documentation to comply with regulatory requirements. The resident involved had diagnoses of muscle weakness, anxiety disorder, and dementia, and was observed asleep in a specialized wheelchair. Interviews with facility staff, including a licensed nurse and an administrative nurse, confirmed the expectation that PRN psychotropic medications should have a 14-day stop date. The facility's policy on medication monitoring also stipulated that PRN psychotropic medications should be used for the shortest duration required, with appropriate documentation. The absence of a stop date or specified duration for the PRN Lorazepam orders placed the resident at risk for unnecessary medication administration and potential adverse side effects.
Lack of Coordination with Hospice Services for Resident
Penalty
Summary
The facility failed to ensure collaboration between the nursing home and hospice services for a resident with severe cognitive impairment and multiple medical diagnoses, including Alzheimer's disease. The resident was dependent on staff for various activities of daily living and was at risk for pressure ulcers. Despite being admitted to hospice services, the resident's care plan lacked documentation related to hospice contact information, equipment, medications, services, and scheduled visits from hospice staff. This omission placed the resident at risk for delayed services and uncommunicated care needs. Observations and interviews revealed that the hospice contact and service information were stored in a separate hospice binder, not integrated into the resident's care plan or Kardex. Staff members, including a CNA and a licensed nurse, confirmed that the care plan did not contain necessary hospice information, and the administrative nurse acknowledged that care plans should include such details. The facility's hospice policy emphasized the need for coordination and communication between the facility and hospice services, which was not effectively implemented in this case.
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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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Nursing homes near Overland Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nottingham Health And Rehabilitation | 0.8 mi | ★★★★★ | 10 | 0 |
| Stratford Commons Rehab & Health Care Center | 1.6 mi | ★★★★★ | 21 | 1 |
| Villa St Francis Catholic Care Center Inc | 2.7 mi | ★★★★★ | 0 | 0 |
| The Plaza Health Services At Santa Marta | 2.7 mi | ★★★★★ | 13 | 0 |
| Tallgrass Creek, Inc | 3.5 mi | ★★★★★ | 15 | 0 |
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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.