Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ignite Medical Resort Overland Park Llc during CMS and state inspections, most recent first.
Unsanitary Food Storage and Preparation Practices: During a kitchen tour, staff observed stained cookware, open and undated ice cream, thawing turkey, numerous pantry items with dates ranging from old stock to expired juice, and a cooler where liquid egg was stored below an unsealed turkey loaf dripping liquid onto it. An LPN-equivalent dietary staff member stated that potentially hazardous foods should be stored separately to prevent cross-contamination and that food should be dated with the month, day, and year.
A resident with paraplegia and bilateral above-the-knee amputations was observed in bed with his call light on the floor and out of reach on multiple occasions. He was alert and oriented, able to use the call light, and stated he could not reach it to ask for help with his menu, nasal cannula, or breakfast. Staff confirmed the call light should have been within his reach, and the facility policy required call lights to remain within reach for residents able to use them.
Failure to provide transfer, bed hold, and ombudsman notifications: A resident had multiple unplanned hospital transfers with anticipated return, but the facility lacked documentation that the resident or representative received written transfer notices and bed hold information, including appeal rights and daily bed hold rates. The facility also lacked proof that the LTC ombudsman was notified of one hospital transfer, and staff stated the paper bed hold form was not scanned into the record.
A resident with multiple chronic conditions, including lymphedema, HF, DM, and depression, had a physician order for ace wraps to both lower legs every Wednesday and Saturday. Records and observations showed the wraps were not consistently applied, the resident was repeatedly seen with swollen legs and no wraps in place, and staff reported the treatment was only completed part of the time. The resident stated the wraps were hit or miss and said she felt depressed and frustrated because the help she needed was not being provided.
Unsafe Hoyer Lift Transfer: Two CNAs transferred a resident with paraplegia and bilateral above-the-knee amputations using a Hoyer lift, but one staff member only held the Foley bag and did not keep hands on the resident while he was suspended in the air. During the transfer, the other CNA briefly removed hands from the lift to answer a call light, and staff interviews confirmed that two-person Hoyer transfers required one staff member to maintain contact with the resident for safety and stabilization.
A facility failed to follow infection control practices during hands-on care for two residents on EBP and failed to store nebulizer equipment properly for another resident. Staff were observed assisting one resident with toileting and incontinence care while wearing only gloves, and another resident’s care involved missing gowns, repeated glove changes without hand hygiene, and contact with emesis and stool. A resident’s nebulizer mask was also found stored in a drawer on top of other items with fluid still in the chamber, rather than being kept in sanitary storage.
Facility Assessment Missing Unit-Based Nursing Staffing Details: The facility failed to complete a thorough facility-wide assessment of nursing staff resources needed for resident care during routine operations and emergencies. The assessment did not identify the specific RN, LPN/LVN, CMA, and CNA staffing levels needed for each unit based on acuity and census, and it lacked staffing levels for each shift and weekends. An Administrative Nurse and Administrative Staff member stated they were not certain the assessment broke down staffing by shift and unit, including weekends.
The facility failed to provide written notice, including the reason for the change, to a resident and/or his representative before assigning a new roommate. One resident with generalized muscle weakness, dementia, intact cognition on BIMS, and identified behavioral issues was verbally informed by Social Services that he would be getting a roommate and agreed, but no written notice specific to the roommate assignment was given. A prior general letter had informed residents that some private rooms would be converted to semi-private and that they might receive a roommate, but it did not state when this would occur. When another resident was admitted as the new roommate, the facility could not produce any written notice for that specific change, and both Social Services and administrative staff acknowledged that only verbal notification was provided and that the room-move policy did not address written notice requirements.
The facility failed to provide written notice to residents and their representatives before room changes, affecting nine residents. The changes were made to create a hall for skilled residents, but the lack of written communication led to dissatisfaction and emotional distress among residents and their families.
A resident experienced significant weight loss due to the facility's failure to monitor and document the effectiveness of nutritional interventions. Despite being on a therapeutic diet, the resident did not receive timely assistance with meals, and there were gaps in the documentation of meal and snack intake. Staff were unaware of the resident's risk for weight loss, leading to continued risk of malnutrition.
A resident with severe cognitive impairment and multiple medical conditions sustained a comminuted distal left femur fracture due to the facility's failure to apply wheelchair pedals and use the required staff assistance for transfers. The care plan required two staff members for transfers and the use of a Broda chair, but these directives were not followed, leading to the resident's injury.
The facility failed to ensure that several residents had access to call lights and proper wheelchair footrests. A resident's call light was out of reach while she was in a recliner, and two other residents had their call lights wrapped around bed rails, making them inaccessible. Additionally, a resident was pushed in a wheelchair without footrests, causing her heels to hit the floor. Staff confirmed that call lights should be within reach and footrests should be used when propelling wheelchairs.
The facility failed to ensure the use of arm bolsters and hand splints for residents, risking a decline in ROM and contractures. A resident with severe cognitive impairment was observed without care-planned arm bolsters on her Broda chair, and staff were unaware of the requirement. Another resident, also with severe cognitive impairment, lacked arm bolsters for positioning. Additionally, two residents were not provided with necessary hand splints, leading to further risk of decreased ROM and mobility.
A survey found that medication and treatment carts in the facility were frequently left unlocked and unattended, contrary to the facility's policy. This was observed across multiple halls, with staff acknowledging that carts should remain locked when not in use. The facility's policy required secure storage of all drugs and biologicals.
The facility failed to follow infection control standards, risking resident safety. Oxygen tubing was improperly stored, and soiled laundry was not adequately separated from clean items. Staff neglected hand hygiene and Enhanced Barrier Precautions during catheter care, using the same gloves for multiple tasks without proper sanitation. These actions violated facility policies aimed at preventing infections.
A resident with multiple sclerosis and paraplegia was found taking medications unsupervised, despite being deemed unable to self-administer safely. The facility's records lacked a physician's order for self-administration, and staff confirmed that no residents were allowed to self-administer medications. The facility's policy required ongoing assessments and interventions, which were not followed.
A facility failed to provide a resident with the CMS Notification of Medicare Non-Coverage Form 10123 (NOMNC) at the end of their Medicare Part A episode. The resident's clinical record lacked evidence of the NOMNC, and the facility did not have a policy for beneficiary notification. Administrative staff confirmed the inability to locate the NOMNC, highlighting a lapse in ensuring residents are informed of their rights and potential financial liabilities.
The facility failed to provide written notification of transfers to two residents or their representatives for facility-initiated transfers to acute hospitals. Both residents, with various medical conditions, were transferred multiple times without the required written notice. Staff interviews confirmed that only verbal notifications were given, and there was no policy for written notifications, posing a risk of miscommunication.
The facility failed to provide bed hold notices to two residents and their representatives during hospital transfers, risking their ability to return to the facility. One resident had conditions including CHF, diabetes, and dementia, while the other had diabetes, dementia, and atrial fibrillation. Both experienced multiple hospital transfers without the required notices, contrary to facility policy.
Two residents with cognitive and physical impairments were not provided adequate assistance during meals, leading to potential risks for impaired nutrition and decline in ADLs. One resident with dementia and hemiparesis was left without timely meal assistance and interaction, while another resident with hemiparesis ate alone without proper utensil placement or staff support. The facility's failure to follow its meal assistance policy contributed to these deficiencies.
The facility failed to implement pressure-reducing measures for two residents at risk for pressure ulcers. One resident's care plan required heel floating, but observations showed heels directly on the mattress. Another resident's care plan included heel protectors and Tubi-grips, but these were not applied. Staff interviews revealed awareness of care plans but inconsistent execution, leading to increased risk for pressure ulcer development.
A resident with an indwelling catheter was not provided appropriate care, as the catheter tubing was observed on the floor, and staff failed to practice proper hand hygiene during catheter care. The resident, with a history of UTIs and other medical conditions, was dependent on staff for toileting hygiene. Observations and staff interviews confirmed non-compliance with facility policies, placing the resident at risk for complications.
A resident with severe cognitive impairment due to dementia was left alone during mealtimes without engagement or entertainment, contrary to her care plan. Staff failed to offer food or drink promptly and did not communicate with her during meals, violating the facility's policy for dementia care.
The facility failed to maintain the kitchen's walk-in refrigerator and freezer unit in safe operating condition, as observed during an inspection. Water was leaking from the unit, and the light inside the freezer was not working. Multiple work orders had been submitted, but the issue remained unresolved due to an impending change of ownership. The facility could not provide a preventative maintenance policy.
Unsanitary Food Storage and Preparation Practices
Penalty
Summary
The facility failed to provide sanitary conditions for food storage and preparation in its kitchen. During an initial tour of the kitchen, Dietary Staff BB observed two small skillets and two small pots with black staining on the interior and exterior surfaces. In the small freezer at the entrance from the dining room, there was an open box of chocolate ice cream cups and an open box of vanilla ice cream with no open date. A small cart contained a plastic bag of thawing, frozen, diced turkey dated 07/19, and the pantry contained multiple food items with dates ranging from 05/12 through 07/24, including cake mixes, brownie mixes, muffin mix, flour, sugar, dry cereal, pancake/waffle mix, oatmeal, peanut butter, salad dressing, and pineapple juice with an expiration date of 07/01/2026. The large cooler also contained food stored in a manner that did not separate potentially hazardous items, including an open carton of liquid egg on the bottom shelf dated 07/27, a turkey loaf wrapped in unsealed, partially open plastic wrap dripping liquid on the third rack above the egg, and a partial crate of eggs on the bottom shelf. The food items had no documentation of the year listed with the dates marked on them. On interview, Dietary Staff BB stated that potentially hazardous foods should be stored separately to prevent cross-contamination and illness, and that food should be dated with the month, day, and year. The facility's Dietary Food Storage policy stated that food and non-food supplies will be purchased, received, and stored under sanitary, safe, and secure conditions as required to meet federal, state, and local laws.
Call Light Left Out of Reach
Penalty
Summary
The facility failed to ensure that Resident 121’s call light was within reach so he could summon staff assistance. Resident 121 had diagnoses of paraplegia, left above-the-knee amputation, and right above-the-knee amputation. His baseline care plan documented that he was a fall risk, that staff should anticipate and meet his needs, and that he did not have cognitive impairment. A daily skilled note documented that he was oriented to person, place, time, and situation but required supervision for safety. During observations, Resident 121 was found lying in bed with his call light on the floor and out of reach on two separate occasions. On one observation, he had his breakfast tray on the over-bed table with a pencil and paper to complete his menu, but he stated he could not reach the call light to ask for help because it was on the floor. On another observation, he again could not reach the call light and stated he could not use it to ask for help with his nasal cannula or to ask about breakfast before leaving for an appointment. Staff interviews confirmed that he was able to use his call light and that it should have been within his reach at all times. The facility policy stated that staff would ensure call lights were within reach of residents who were able to cognitively use them each time staff left the room.
Failure to Provide Transfer, Bed Hold, and Ombudsman Notifications
Penalty
Summary
The facility failed to ensure the Office of the Long Term Care Ombudsman was notified when a resident was transferred to the hospital, and failed to ensure the resident and representatives were provided written transfer information and bed hold information. Record review showed the resident had multiple unplanned hospital discharges with anticipated return and subsequent re-entries to the facility. For the resident’s transfers to the hospital on [DATE], 08/20/2025, and 03/05/2025, the facility lacked proof or documentation that the resident or representative received the bed hold information or written notice of transfer. The facility also lacked proof or documentation that the LTC ombudsman was notified of the resident’s 03/05/2026 transfer to the hospital. The facility’s Bed Hold Notice form included bed hold information, appeal rights, LTC ombudsman information, and the private and semi-private daily rates to hold the bed, along with spaces for staff to document the transfer destination, reason, and date. On 07/29/2026, Administrative Staff A stated nurses completed a bed hold assessment in the EMR and called the representative about the bed hold, but the paper form completed by staff was not scanned into the resident’s record. Administrative Staff A also stated the social worker submitted transfers and discharges to the state ombudsman monthly and could not state why the resident’s hospital transfer had been omitted from the list.
Failure to Follow Ordered Leg Wrap Treatment
Penalty
Summary
The facility failed to ensure appropriate care and services were provided to promote wound healing when staff did not follow the physician’s order for bilateral lower-extremity ace wraps. The resident had multiple documented diagnoses including COPD, elevated WBC count, kidney failure, sepsis, DM, depression, HF, lymphedema, and a history of thrombosis and embolism. The care plan documented actual impairment to skin integrity and directed staff to evaluate and treat per physician order. The physician ordered nursing staff to apply ace wraps lightly to both lower extremities up to the knee every Wednesday and Saturday, with wrap changes on shower days. Record review and observations showed the resident’s legs were swollen and the ace wraps were not consistently in place. A pulmonary follow-up note documented the resident presented with swollen bilateral legs and that the legs were wrapped but had not been wrapped for several days prior. The MAR showed the wraps were documented as applied each Wednesday and Saturday, but the EHR lacked evidence that the resident refused the wraps. During observations, the resident stated the wraps were supposed to be done on Wednesday and Saturday but were not always done, and she reported feeling depressed and frustrated because she was not receiving the help she needed. She was observed multiple times with visibly swollen legs and no ace wraps on either leg. CNA and nursing staff stated the wraps were often not on the resident’s legs and were only done part of the time.
Unsafe Hoyer Lift Transfer
Penalty
Summary
The facility failed to provide an environment free from accident hazards when staff transferred a resident using a full body Hoyer lift without maintaining direct contact for safety and stabilization during the transfer. The resident had diagnoses of paraplegia, a left above-the-knee amputation, and a right above-the-knee amputation. He was admitted on [DATE], had no MDS assessment completed at the time of survey, and his baseline care plan dated 07/26/2026 identified him as a fall risk, noted that he did not have cognitive impairment, and required maximum assistance for transfers. A skilled note dated 07/24/2026 documented that he was oriented to person, place, time, and situation but required supervision for safety. During observation on 07/28/2026 at 09:07 AM, two CNAs placed the Hoyer sling under the resident and lifted him from the bed toward his wheelchair. While the resident was suspended in the air and transferred over the chair, one CNA operated the lift while the other held the Foley catheter urine bag and walked around the bed, but did not maintain contact with the resident during the transfer. A staff member knocked on the door and told the CNAs the call light was on, and the CNA operating the lift removed his hands from the Hoyer to turn off the call light while the resident remained suspended. The resident was then lowered into the wheelchair, and only at that point did the second CNA place one hand on him to adjust him in the chair. Staff interviews stated that two staff members were required for Hoyer transfers, that one staff member should keep a hand on the resident during the transfer, and that the resident should never be left suspended without someone having hands on him.
Infection Control Lapses With EBP, Hand Hygiene, and Respiratory Equipment Storage
Penalty
Summary
The facility failed to provide adequate infection control practices related to Enhanced Barrier Precautions (EBP), personal protective equipment (PPE), and hand hygiene while providing direct care to two residents. R120 had EBP signage on his door for wound care on his backside and right lower leg, but staff observed assisting him with toileting and incontinence care wore only gloves. During one episode, a CMA assisted R120 to the bathroom, removed wet clothing, cleaned the wheelchair cushion, retrieved clean pants from the closet, and applied a new brief and pants without changing gloves or performing hand hygiene. Staff interviews reflected that EBP required gown and gloves during hands-on care, and the Administrative Nurse stated all staff were expected to wear PPE when a resident required EBP. R29 also had EBP signage and PPE located outside the room, but a CNA entered without performing hand hygiene and initially applied only gloves, not a gown. While gathering supplies from the closet, R29 had emesis twice, and the CNA cleaned the resident’s face and then continued incontinent care. During the care, the CNA removed gloves and reapplied new gloves multiple times without hand hygiene, while cleansing bowel movement from the resident’s buttocks and applying a brief. The CNA later stated she had forgotten to put on her gown and did not know she had to wash her hands after removing gloves during care, while the LN reported she instructed the CNA to wear a gown when providing hands-on care to residents on EBP. The facility also failed to store respiratory equipment properly for R41. The nebulizer mask was observed in the resident’s drawer lying directly on other items, with clear fluid remaining in the chamber, and the call touch pad was laid directly in the mask. This condition was observed on multiple occasions while the resident was in therapy, then later in bed, and again the next morning. When the nebulizer treatment was later administered, the mask was taken from the drawer and the albuterol vial was squeezed into the chamber. The LN reported there was a bag the mask should be placed in when the treatment was finished, and the Administrative Nurse stated the nebulizer equipment should be rinsed out after use, air dried, and placed in a bag when not in use.
Facility Assessment Missing Unit-Based Nursing Staffing Details
Penalty
Summary
The facility failed to conduct a thorough facility-wide assessment to determine the nursing staff resources necessary to care for residents competently during day-to-day operations and emergencies. Review of the Facility Assessment dated 03/22/2026 showed that it did not identify the specific staffing levels needed for each unit or the number of RN, LPN/LVN, CMA, and CNA staff needed for each unit based on resident acuity and census. The assessment also did not include the staffing levels required for each daily shift or for weekends. During interviews on 07/29/2026, Administrative Nurse D stated that the facility assessment should reflect the total hours for each nursing staff, but could not state for certain whether it broke down each required nursing staff per shift. Administrative Staff A stated the Facility Assessment was reviewed annually and information was included per the new guidelines, but she was not aware that the staffing plan needed to be broken down for each category of nursing staff each shift and for each unit, including weekends. The facility policy dated 08/01/2024 stated the Facility Assessment would address resident population, staff competencies and skill set, physical environment, equipment, services, personnel, contracts, and an all-hazards risk assessment.
Failure to Provide Written Notice Before Roommate Assignment
Penalty
Summary
The facility failed to provide written notice, including the reason for the change, to a resident and/or his representative before assigning him a new roommate. The resident had diagnoses of generalized muscle weakness and dementia with behavioral disturbances, but his most recent MDS documented a BIMS score of 15, indicating intact cognition, and his CAA noted he was highly active in his ADLs and preferred to do what he could for himself. His care plan identified a behavior problem and directed staff to administer medications as ordered and monitor behavior episodes. A social service note documented that on 02/11/26, staff verbally notified the resident that he would be getting a roommate in the next couple of days, and the resident verbalized understanding and agreement. The facility produced a general notice, dated 11/26/24, addressed to the resident and his representative, stating that effective 01/01/25 the facility would be transitioning some private rooms to semi-private accommodations and that if the resident received the letter, his room was one being converted. This notice did not specify when he would actually receive a roommate. The resident received a roommate when another resident was admitted on 02/13/26, but the facility was unable to provide any written notice specific to that roommate assignment. During interviews, the resident stated he never received written notice prior to the roommate moving in and was only told verbally. Social Services staff confirmed she verbally informed the resident and documented a note but did not provide written notice, and administrative staff confirmed residents were told at least the day before they were getting a roommate but not in writing. The facility’s Room Moves policy directed Social Services to inform residents and families of room moves but did not address written notice of room or roommate changes.
Failure to Provide Written Notice for Room Changes
Penalty
Summary
The facility failed to honor the residents' rights to receive written notice before a room change, affecting nine residents. The room changes were made to create a hall for skilled residents, but the facility did not provide written notifications to the residents or their representatives. This oversight placed the residents at risk for impaired rights and decreased psychosocial well-being. Several residents, including those with intact cognition and those with severely impaired cognition, were moved from their rooms without receiving written notice. For instance, one resident with a BIMS score indicating intact cognition was agreeable to the move but did not receive written notification. Another resident with severely impaired cognition was informed verbally, but their representative did not receive written notice. The facility's policy required written notification, but this was not adhered to. Interviews with residents and their representatives revealed dissatisfaction and emotional distress due to the lack of written communication and the inability to choose to stay in their original rooms. Some residents expressed feelings of being treated like numbers or objects, and others were concerned about the potential for room sharing in larger rooms. The facility's policy on room moves was not followed, leading to the deficiency.
Failure to Monitor Weight Loss Interventions
Penalty
Summary
The facility failed to adequately monitor and address the weight loss interventions for a resident, identified as R1, who experienced significant weight loss. R1's medical records indicated a need for assistance with personal care, difficulty in walking, and dysphagia, among other conditions. Despite being on a therapeutic diet and having a care plan that included monitoring for changes in intake patterns and providing snacks and beverages, the facility did not consistently document or ensure the effectiveness of these interventions. R1's weight dropped from 173 pounds upon admission to 160 pounds, and there were gaps in the documentation of meal and snack intake. Observations and interviews revealed that R1 often did not receive timely assistance with meals, including delays in receiving beverages and inadequate help with food preparation. R1 reported dissatisfaction with the meal options and noted that staff frequently left food trays without ensuring he was aware or able to consume the meals. Additionally, R1 expressed a preference for certain nutritional supplements, which were not consistently provided according to his preferences, further complicating his nutritional intake. The facility's policy required weight change investigations for significant weight changes, but there was a lack of consistent follow-up and documentation regarding R1's nutritional intake and the effectiveness of interventions. Staff interviews indicated a lack of awareness about which residents were at risk for weight loss and the necessary interventions. This oversight placed R1 at risk for continued weight loss and malnutrition, as the facility did not adequately monitor or adjust the interventions to address his nutritional needs.
Failure to Ensure Safe Transfers and Wheelchair Use
Penalty
Summary
The facility failed to ensure an environment free from avoidable accidents for a resident, identified as R72, when staff did not apply wheelchair pedals to her chair while being propelled by staff and did not use the required amount of staff assistance for transfers. This resulted in R72 sustaining a comminuted distal left femur fracture. The deficiency was identified through a combination of record reviews, interviews, and observations. R72's medical history included a need for continuous supervision, aphasia following a stroke, gastroesophageal reflux, hypertension, hyperlipidemia, atrial fibrillation, malignant neoplasm of the skin, and anemia. The resident was documented to have severely impaired cognition and required substantial to maximal assistance for various activities of daily living. R72's care plan specified the use of a sit-to-stand lift with two staff members for transfers, and the use of a Broda chair for mobility, indicating the resident's dependency on staff for safe transfers and mobility. Interviews and observations revealed that staff did not adhere to the care plan's directives. On the day of the incident, a CNA used a sit-to-stand lift alone to transfer R72, contrary to the care plan's requirement for two staff members. Additionally, R72's wheelchair lacked foot pedals, which were necessary for safe propulsion by staff. The absence of foot pedals and inadequate staff assistance during transfers were significant factors contributing to the resident's injury.
Failure to Provide Accessible Call Lights and Wheelchair Footrests
Penalty
Summary
The facility failed to ensure that several residents had access to call lights, which are essential for requesting assistance. Specifically, Resident 11, Resident 43, and Resident 80 were observed without reachable call lights. Resident 80's call light was found in the middle of her bed while she was seated in a recliner, making it inaccessible. Similarly, Resident 43's call light was wrapped around her bed rail while she was in a Broda chair, and Resident 11's call light was also wrapped around his bed rail while he was in a wheelchair eating lunch. These observations indicate a failure to provide necessary accommodations for residents to communicate their needs effectively. Additionally, the facility did not provide footrests for Resident 72's wheelchair, resulting in her heels hitting the floor as she was pushed to the dining room. This practice was confirmed as inappropriate by both a Certified Nurse's Aide and a Licensed Nurse, who stated that footrests should be used when propelling wheelchairs and that call lights should always be within residents' reach. The facility's Accommodation of Needs policy emphasizes the importance of maintaining residents' independent functioning, dignity, and well-being, which was not upheld in these instances.
Failure to Implement Supportive Devices for Residents
Penalty
Summary
The facility failed to ensure the proper use of arm bolsters and hand splints for several residents, which placed them at risk for a decline in range of motion (ROM) and contractures. Resident 73, who had severe cognitive impairment and was dependent on staff for various activities, was observed without the care-planned arm bolsters on her Broda chair. Despite the care plan indicating the need for these bolsters, there were no physician orders or therapy notes documenting their use, and staff members were unaware of the requirement. Similarly, Resident 44, who had severe cognitive impairment and was dependent on staff for positioning, was also observed without arm bolsters on her Broda chair. The care plan specified the use of these bolsters for positioning, but staff members, including a CNA and an agency nurse, were not aware of this requirement. The facility's policy on the accommodation of needs was not followed, leading to a lack of appropriate positioning support for the resident. Additionally, Residents 75 and 11 were not provided with the necessary hand splints as ordered. Resident 75, who had severe cognitive impairment and functional limitations, was observed without her right-hand splint, which was supposed to be worn at all times except during showers and hand hygiene. Staff reported that the splint caused discomfort and bruising, leading to its non-use. Resident 11, who had moderately impaired cognition and right-sided hemiparesis, was also observed without the required hand splint or a rolled washcloth in his right hand. The facility's failure to implement these supportive devices as care planned left the residents at risk for further decline in ROM and mobility.
Medication Storage Deficiency
Penalty
Summary
The facility failed to properly store medications, as observed during a survey involving a sample of 18 residents and multiple medication and treatment carts. On several occasions, medication carts on various halls, including C-hall, B-hall, F-hallway, G-hall, E-hall, A-hall, and P-hall, were found unlocked and unattended in the hallways. This included instances where medication carts contained plastic cups with unlabeled pills. The facility's policy, last reviewed in January 2024, required that all drugs and biologicals be stored securely and that carts should not be left unattended if open or potentially accessible to others. Interviews with nursing staff, including agency Licensed Nurses K, H, and J, confirmed that the expectation was for medication and treatment carts to remain locked when not in use. Administrative Nurse D also stated that she expected nurses to keep these carts locked. Despite these expectations and the facility's policy, the surveyors found multiple instances of non-compliance, which could potentially lead to adverse consequences or ineffective treatment for the residents.
Infection Control Deficiencies in Sanitation and Hand Hygiene
Penalty
Summary
The facility failed to adhere to sanitary infection control standards, which placed residents at risk for infectious diseases. Observations revealed that oxygen tubing was not stored in sanitary containers when not in use, as seen with two residents whose nasal cannulas were improperly stored. Additionally, staff were observed handling soiled laundry without proper containment, as unbagged linens were pressed against a staff member's body, and soiled clothing was stored next to clean laundry without appropriate separation. These practices were contrary to the facility's policies on laundry and linen handling. Further deficiencies were noted in hand hygiene and the implementation of Enhanced Barrier Precautions (EBP). During catheter care for a resident, a CNA failed to perform hand hygiene before donning gloves and did not wear a gown as required by EBP. The CNA also used the same gloves for multiple tasks, including cleaning the resident's peri area, without changing them or performing hand hygiene. An administrative nurse also failed to perform hand hygiene before donning gloves and did not wear a gown while assisting with a resident's transfer. These actions were inconsistent with the facility's policies on peri care and EBP, which are designed to prevent infections and ensure resident safety.
Failure to Ensure Safe Medication Self-Administration
Penalty
Summary
The facility failed to ensure that Resident 53 was safe to self-administer her medications, which placed her at risk for medication complications and administration errors. Resident 53 had a medical history that included multiple sclerosis, paraplegia, and obstructive uropathy, and she required total staff assistance for various activities of daily living. Despite having intact cognition as indicated by a BIMS score of 15, her care plan noted impaired memory, decision-making, and comprehension, and there was no documentation indicating she could safely self-administer her medication. Furthermore, the facility's records lacked a physician's order for medication self-administration, and an evaluation had previously deemed her unable to safely self-administer medications. Observations revealed that Resident 53 was found taking her morning medications unsupervised, with her bedside table containing a cup of water and two small plastic pill cups filled with numerous medications. Staff were not present in the room at the time. Interviews with facility staff confirmed that Resident 53 should not have been taking her medications unsupervised, and that no residents in the facility were currently able to self-administer their own medications. The facility's policy required ongoing assessments and care-planned interventions for residents identified as safe for self-administration, which were not adhered to in this case.
Failure to Issue Medicare Non-Coverage Notification
Penalty
Summary
The facility failed to issue the Center for Medicare/Medicaid Services (CMS) Notification of Medicare Non-Coverage Form 10123 (NOMNC) to a resident, identified as R139, at the end of their Medicare Part A episode. The resident's Medicare Part A coverage began on April 10, 2024, and ended on April 27, 2024, but there was no evidence in the clinical record that the NOMNC was provided. This form is crucial as it informs Medicare A participants of their rights to appeal and the last covered date, indicating potential financial liability when a Medicare Part A episode ends. During an interview on July 16, 2024, Administrative Staff A confirmed the facility's inability to locate the NOMNC for R139. Additionally, the facility did not have a policy in place for beneficiary notification, which contributed to the oversight.
Failure to Provide Written Notification of Transfers
Penalty
Summary
The facility failed to provide timely written notification of transfer or discharge to two residents, R13 and R56, or their representatives for facility-initiated transfers to acute hospitals. This deficiency was identified during a survey that included a sample of 18 residents, with four specifically sampled for transfer and discharge. The lack of written notification was noted for multiple instances of hospital transfers for both residents, which were documented in their electronic medical records and nurse's progress notes. Resident R13, who had diagnoses including congestive heart failure, diabetes mellitus, and dementia, experienced several facility-initiated transfers to an acute hospital due to medical conditions such as increased thirst, shortness of breath, and aspiration pneumonia. Despite these transfers, the facility did not provide the required written notification to R13 or their representative. Interviews with administrative staff revealed that only verbal notifications were given, and there was no policy in place for written notifications. Similarly, Resident R56, with diagnoses including diabetes mellitus, dementia, and atrial fibrillation, was transferred to an acute hospital multiple times due to symptoms like tremors, confusion, and falls. The facility also failed to provide written notifications for these transfers. Interviews with staff confirmed that the family was only notified by phone, and there was no formal written notification process in place. This deficiency posed a risk of miscommunication between the facility and the residents' families.
Failure to Provide Bed Hold Notices for Hospital Transfers
Penalty
Summary
The facility failed to provide a bed hold notice to two residents, R13 and R56, and their representatives when they were transferred to the hospital. This deficiency was identified during a survey that included a sample of 18 residents, with four residents specifically sampled for transfer and discharge. The absence of a bed hold notice placed these residents at risk for impaired ability to return to the facility or their same room. Resident R13 had a history of congestive heart failure, diabetes mellitus, and dementia, with documented episodes of confusion and impaired cognition. R13 required assistance with activities of daily living and had multiple hospital transfers due to health issues such as increased thirst, shortness of air, and aspiration pneumonia. Despite these transfers, the facility was unable to provide evidence of a bed hold notice for R13's hospitalizations on several occasions. Similarly, Resident R56, who had diagnoses including diabetes mellitus, dementia, atrial fibrillation, and cerebral infarction, experienced multiple hospital transfers due to health concerns such as tremors, confusion, and falls. The facility also failed to provide a bed hold notice for R56's hospitalizations. The facility's policy required that a written notice specifying the duration of the bed hold be provided to residents and their representatives at the time of transfer, but this was not adhered to, as evidenced by the lack of documentation for both residents.
Failure to Assist Residents During Meals
Penalty
Summary
The facility failed to provide necessary assistance to two residents, R10 and R11, during mealtimes, which compromised their ability to maintain their highest practicable level of independence in activities of daily living (ADLs). R10, who has dementia, anxiety disorder, left-sided hemiparesis, and insomnia, was observed on multiple occasions to be left without timely assistance during meals. Despite her care plan indicating the need for items to be placed on her right side due to left-sided weakness, staff failed to do so, resulting in R10 struggling to access her food and drink. Additionally, R10 was left alone without interaction or cueing from staff, which is contrary to the facility's policy on meal assistance. R11, who has a history of right-sided hemiparesis following a cerebrovascular accident, hypertension, and obesity, was also not provided adequate assistance during meals. R11 was observed eating breakfast alone in his room, using his fingers to eat after his spoon fell to the floor, without any staff checking on him. His care plan required staff to place utensils on his left side for easier reach and to assist him as needed, but this was not adhered to, leaving R11 without the necessary support to maintain his ADL abilities. The facility's failure to adhere to its Assistance with Meals policy, which mandates supervision, cueing, and guidance during meals, resulted in both residents being at risk for impaired nutrition and a decline in their ADLs. Staff interviews revealed a lack of consistent adherence to care plans and meal assistance protocols, contributing to the deficiencies observed in the care of R10 and R11.
Failure to Implement Pressure-Reducing Measures for Residents
Penalty
Summary
The facility failed to implement pressure-reducing measures for two residents, R11 and R80, who were at risk for pressure ulcer development. R11, diagnosed with hemiparesis, hypertension, obesity, and lymphedema, had a care plan that required staff to assist with turning and repositioning every two hours and to float his heels using pillows. Despite these measures, observations on two consecutive days revealed that R11's heels were directly on the mattress without any pillows to float them. Staff interviews confirmed awareness of the care plan requirements, yet the necessary actions were not consistently executed. R80, also diagnosed with hemiparesis, hypertension, dysphagia, depression, and renal failure, was dependent on staff for all activities of daily living and had a care plan that included the use of heel protectors and Tubi-grips. Observations showed that R80's heels were not floated, and her boot was not applied as ordered. Staff interviews indicated a lack of clarity and access to the care plan, resulting in the failure to apply the necessary pressure-reducing devices. The facility's Prevention of Pressure Injuries Protocol, revised in 2018, emphasizes the importance of repositioning and using pressure-reducing devices to prevent pressure injuries. However, the facility did not adhere to these protocols for R11 and R80, placing them at increased risk for pressure ulcer development. The lack of consistent implementation of care plans and staff awareness contributed to this deficiency.
Inadequate Catheter Care and Hygiene Practices
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, identified as R11, by allowing the catheter drainage bag tubing to rest on the floor and not practicing proper hand hygiene during catheter care. R11's medical history included hemiparesis due to a cerebrovascular accident, hypertension, obesity, and a history of urinary tract infections (UTIs). The resident was dependent on staff for all toileting hygiene and had a care plan that required the catheter drainage bag to be kept below the bladder level and off the floor, with tubing secured to the leg. Observations revealed that on one occasion, R11's catheter tubing was found lying on the floor under the wheelchair while the resident was eating breakfast. On another occasion, a Certified Nurse Aide (CNA) placed the catheter bag and tubing on the bed without donning personal protective equipment or performing hand hygiene, despite the resident being on enhanced barrier precautions. The CNA also failed to perform hand hygiene after removing gloves and used the same towel to dry the resident's front peri/catheter area after cleaning. Interviews with staff confirmed that catheter tubing should not touch the floor as it could lead to complications, including UTIs. The facility's policy on urinary catheter care required the use of standard precautions when handling the drainage system. The failure to adhere to these protocols placed the resident at risk for catheter-related complications and further UTIs.
Failure to Provide Dementia-Related Care During Mealtimes
Penalty
Summary
The facility failed to provide appropriate dementia-related care to a resident, identified as R73, during mealtimes. R73, who has severe cognitive impairment due to dementia, was observed on multiple occasions being left alone in the dining room without any engagement or entertainment, such as music or conversation. Despite her repeated vocalizations, no staff or other residents were present to interact with her. Additionally, R73 was not offered food or drink while waiting, and when meals were eventually served, the staff did not communicate with her or offer her choices, which is contrary to the care plan that required staff assistance and cueing during meals. The observations revealed that the staff did not adhere to the facility's policy of providing supervision and supportive care to residents with cognitive impairments. The staff failed to engage with R73, leaving her unsupervised and without social interaction, which is against the expectations set by the facility's administrative nurse. The facility's policy emphasized individualized interventions and continuous supervision, which were not followed, placing R73 at risk for unmet care needs and impaired quality of life.
Failure to Maintain Safe Operating Condition of Kitchen Equipment
Penalty
Summary
The facility failed to ensure that the kitchen's walk-in refrigerator and freezer unit was in safe operating condition. During an inspection of the main kitchen, it was observed that a blanket and towels were placed on the floor at the base of the walk-in refrigerator and freezer unit due to water leaking from the unit. The water was flowing to a drain on the floor, and the light inside the walk-in freezer compartment was not functioning. The facility's Work Orders Summary report indicated multiple work orders had been submitted over a period of time, highlighting ongoing issues with excessive water leakage from the walk-in unit. Dietary Staff AA confirmed the presence of a leak between the refrigerator and freezer compartments and mentioned that a repairman was expected to address the issue. Administrative Staff A acknowledged awareness of the work orders and stated that the corporate office had been notified, but the situation remained unresolved due to an impending change of ownership. The facility was unable to provide a preventative maintenance policy upon request, further indicating a failure to maintain mechanical equipment in safe operating condition.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| Village Shalom Inc | 1.1 mi | ★★★★★ | 0 | 0 |
| Tallgrass Creek, Inc | 1.4 mi | ★★★★★ | 15 | 0 |
| The Healthcare Resort Of Leawood - Iron Horse Hlth | 1.5 mi | ★★★★★ | 1 | 1 |
| Brookdale Overland Park | 1.6 mi | ★★★★★ | 11 | 0 |
| Advanced Health Care Of Overland Park | 3.2 mi | ★★★★★ | 2 | 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 October 2026) and official state health department websites.