Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Kaw River Care And Rehab during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and physical limitations developed a second-degree burn on the left arm and shoulder of unknown origin after exhibiting increased pain, resistance to care, and unusual behavior. Staff were unable to fully assess or document the resident's complaints, and the injury was discovered only after multiple attempts to provide care. The facility's investigation did not determine the cause of the burn, and documentation and assessment practices were found to be inconsistent.
Staff failed to follow transfer protocols and use a gait belt for a resident with hemiplegia, resulting in a fall and hip fracture, and did not implement required fall prevention interventions for another resident with cognitive impairment and a history of falls, as nonskid strips were missing from the bathroom. Communication lapses among staff contributed to these deficiencies.
The facility did not consistently provide structured or varied activities for residents on weekends, as shown by activity calendars and confirmed by resident council members and staff interviews. Residents reported limited engagement, often only watching TV or reading, and staff acknowledged not leading activities on weekends, contrary to facility policy.
The facility did not complete required annual performance reviews for several CNAs and a CMA who had been employed for over a year, and lacked a policy for nurse aide performance evaluations. Documentation confirming performance reviews within the past 12 months was not available for these staff members.
Surveyors found that three opened insulin pens were not dated, an unlocked and unattended medication cart was left in a hallway, and expired vaccines were stored in the medication refrigerator without proper temperature log documentation. Administrative and licensed staff confirmed these practices did not follow facility policy for medication security and labeling.
A resident with severe cognitive and physical impairments, including an indwelling catheter, was repeatedly observed with their catheter collection bag visible from the hallway and not covered by a dignity bag. Staff interviews confirmed that the expectation was to cover catheter bags or place them out of view, but this was not done, contrary to facility policy on resident dignity.
Two residents received PRN Ativan orders for anxiety without the required 14-day stop date, despite facility policy and staff acknowledgment of this requirement. One resident had severe cognitive impairment and multiple diagnoses, while the other had intact cognition but significant physical and behavioral needs. Nursing staff and administration confirmed that the omission of the 14-day limit was contrary to established procedures.
A resident with significant mobility impairments and a history of falls was transferred by a single CNA without a gait belt, contrary to the care plan requiring two-person assistance. The resident fell, sustained a hip fracture, and required hospitalization and surgery. Despite the major injury, administrative staff did not report the incident to the State Agency, citing the resident's initial communication and delayed onset of severe pain.
The facility did not provide required bed hold notices to a resident with multiple chronic conditions upon hospitalization, nor did it provide written transfer notifications to another resident with severe cognitive and physical impairments during multiple unplanned discharges to an acute hospital. Administrative staff confirmed these notifications were not consistently given, contrary to facility policy.
A resident with complex medical needs, including a tracheostomy and decreased mobility, did not have a care plan that included staff instructions for ADL care and functional assistance. Staff interviews revealed that CNAs lacked access to the care plan and relied on nurses for special instructions, while administrative staff discussed interventions in meetings but did not ensure comprehensive, measurable objectives for ADL support were documented.
A resident with multiple complex medical conditions and a history of repeated falls did not have their care plan consistently updated with new interventions after each fall. Despite documented incidents where the resident was found on the floor and sometimes unable to recall the event, the care plan was not revised in accordance with facility policy, and staff communication about interventions was inconsistent.
A resident with hemiparesis following a stroke did not receive restorative range of motion (ROM) exercises or therapy, despite a care plan indicating the need to maintain or improve mobility and prevent contractures. Staff and administration confirmed the absence of a restorative therapy program, and the resident reported never having received ROM exercises since admission.
The facility did not include the daily census number on posted nurse staffing sheets for an extended period, as required. This omission was confirmed during a review of records and through interviews with administrative staff, who acknowledged the deficiency.
The facility did not ensure a clear and documented communication process with hospice providers for two residents receiving hospice care. Care plans lacked evidence of collaboration, and staff were uncertain about accessing hospice information, supplies, and care details. This resulted in incomplete documentation and potential gaps in care coordination between the facility and hospice services.
A resident with cognitive impairments made racially derogatory remarks towards a CNA, leading to a loud verbal altercation in the dining room. The CNA responded unprofessionally, drawing attention from other staff and residents, which violated the facility's policy on treating residents with dignity and respect.
Failure to Protect Cognitively Impaired Resident from Injury of Unknown Origin
Penalty
Summary
A cognitively impaired resident with a history of vascular dementia, cerebrovascular disease, and significant physical and cognitive limitations sustained a second-degree burn of unknown origin to the left arm and shoulder. The resident was known to be at high risk for falls, had impaired decision-making, and required substantial assistance with activities of daily living. In the days leading up to the injury, the resident became increasingly combative, resistant to care, and complained of pain, but refused interventions. Documentation in the medical record noted pain complaints and resistance to care, but lacked specific details about the location of pain or the interventions offered. On the day the injury was discovered, multiple CNAs attempted to provide care but were met with combative behavior and were only able to change the resident's brief, leaving other clothing unchanged due to resistance. The resident remained in bed on the left side for an extended period, which was unusual for his baseline activity level. Staff noted the resident was not acting like himself, was in visible distress, and repeatedly complained of pain, particularly in the left arm and leg. When staff were finally able to reposition the resident, they discovered significant skin sloughing and blistering on the left arm, consistent with a second-degree burn. The injury was not present the previous day, and the resident was subsequently sent to the hospital for evaluation. The facility's investigation was unable to determine the cause of the burn. Environmental checks, review of meals and linens, and staff interviews did not reveal any source of hot fluids or environmental hazards. The investigation also noted inconsistent documentation and assessment practices, with staff failing to fully assess or document the resident's complaints of pain and changes in behavior. The lack of thorough assessment and documentation, combined with the resident's cognitive impairment and inability to communicate the cause of the injury, resulted in the resident sustaining a significant injury of unknown origin.
Failure to Ensure Safe Transfers and Implement Fall Interventions
Penalty
Summary
A deficiency occurred when staff failed to provide a safe environment free from accident hazards for a resident with hemiplegia and a history of falls. The resident required two-person assistance and the use of a gait belt for transfers, as documented in her care plan following a previous fall with major injury. Despite these directives, a new CNA transferred the resident alone and without a gait belt after the resident insisted on immediate assistance. During the transfer, the resident lost her balance and fell, resulting in a hip fracture that required hospitalization and surgical intervention. The CNA later acknowledged feeling pressured and not following established protocols due to the resident's insistence and a busy shift. Additionally, the facility failed to implement and maintain new fall prevention interventions for another resident with multiple diagnoses, including cognitive impairment, muscle weakness, and a history of repeated falls. The care plan for this resident included the placement of nonskid strips in the bathroom as a fall intervention following a previous incident. However, observations on multiple occasions revealed that the nonskid strips were not present in the resident's bathroom, indicating that the intervention was not carried out as planned. Interviews with staff revealed inconsistencies in how fall interventions were communicated and implemented. Some CNAs reported relying on nurses for updates about new interventions, while others referenced a communication board, but there was uncertainty about how effectively this information was shared. The facility's own policy required prompt investigation and documentation of accidents and incidents, but the lack of follow-through on care plan interventions and proper transfer protocols contributed to preventable falls and injuries for both residents.
Inconsistent Weekend Activities Provided for Residents
Penalty
Summary
The facility failed to provide consistent and varied weekend activities for its residents, as evidenced by a review of the activity calendars for March, April, and May 2025, and interviews with residents and staff. While the calendars listed some activities such as hydration carts, daily chronicles, activity carts, movie matinees, TV worship, and occasional special events, resident council members reported that activities rarely occurred on weekends and lacked variety even on weekdays. Residents stated that they typically watched TV or read during weekends and expressed a desire for more interactive group activities led by staff. Staff interviews further revealed that activities staff allowed residents to "do their own thing" on weekends, leaving the activity cart available but not actively facilitating activities. A CNA confirmed that she did not conduct activities on weekends when she worked. The facility's own policy required the provision of activities on all days, including weekends and holidays, but this was not consistently implemented, resulting in a lack of structured and engaging activities for residents during weekends.
Failure to Complete Annual Nurse Aide Performance Reviews
Penalty
Summary
The facility failed to complete the required annual performance reviews for nurse aides and a certified medication aide, as evidenced by the lack of documentation for performance evaluations within the past 12 months for multiple staff members who had been employed for over a year. A review of the staffing list showed that several CNAs and a CMA did not have records of a performance review being conducted in the last 12 calendar months. Additionally, the facility did not have a policy in place for conducting nurse aide performance evaluations. This deficiency was confirmed through record review and staff interview, with administrative staff unable to locate evidence of completed performance reviews as required.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed that three opened insulin pens on the east hall nurse medication and treatment cart were not dated when opened, as required by facility guidelines. Licensed staff confirmed the lack of dating, which is necessary to ensure insulin pens are disposed of 28 days after opening. Additionally, the west hall nurse treatment cart was found unlocked and unattended, with administrative staff confirming that medication carts should not be left unsecured when not in the direct presence of licensed staff. A licensed nurse was located nearby but not attending the cart at the time. Further observations revealed that the medication room refrigerator contained expired medications, including two vials of Prevnar 23 vaccine and three vials of Moderna COVID-19 vaccine, as well as missing temperature log documentation for the month. Administrative staff verified that expired medications should be removed from use and that insulin pens should be dated upon opening. Facility policies require all drugs and biologicals to be stored securely, with expired or discontinued medications removed from use, and medication carts locked when unattended.
Failure to Provide Dignity Bag for Catheter Collection Bag
Penalty
Summary
Staff failed to respect a resident's right to dignity by not providing a dignity bag to cover the resident's indwelling catheter collection bag. The resident, who had multiple complex medical conditions including multiple sclerosis, seizures, respiratory failure, pneumonia, pressure ulcers, and required a gastrostomy tube and supplemental oxygen, was completely dependent on staff for all activities of daily living. The resident's care plan directed staff to keep the catheter bag below the level of the bladder and to provide routine catheter care, but did not include instructions to use a dignity bag to cover the catheter collection bag. On multiple occasions, surveyors observed the resident lying in bed with the catheter collection bag visible from the hallway and not covered by a dignity bag. Interviews with nursing staff and administration confirmed that the expectation was for catheter bags to be covered with a dignity bag or placed on the side of the bed away from the doorway, both when the resident was in and out of the room. The facility's policy emphasized the right of residents to a dignified existence and to be treated with respect, but this was not followed in the observed instances.
Failure to Include 14-Day Stop Date on PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that as-needed (PRN) antianxiety medication orders for two residents included a required 14-day time limit, as mandated for psychotropic medications. For one resident with multiple diagnoses including psychotic disorder, major depressive disorder, epilepsy, and vascular dementia, the electronic medical record showed an active PRN order for Ativan (lorazepam) without a 14-day discontinuation date. This resident had severely impaired cognition and required significant assistance with daily activities. The care plan noted the use of high-risk medications and directed staff to limit dosages and durations, but the PRN Ativan order did not comply with the 14-day requirement. A second resident, with diagnoses including hemiplegia following a stroke, major depressive disorder, and insomnia, also had a PRN Ativan order lacking a 14-day stop date. This resident had intact cognition but required substantial to total assistance with functional abilities and had a history of behavioral issues. The care plan directed staff to administer medications as ordered and monitor for side effects, but the PRN order for Ativan did not include the necessary time limitation. Interviews with nursing staff and administration confirmed that the responsibility for ensuring correct order entry, including the 14-day stop date for PRN psychotropic medications, rested with the nurse taking off the order. Both the facility's policy and staff statements acknowledged the requirement for a 14-day limit on PRN psychotropic medications, but this was not implemented for the two residents in question.
Failure to Report Major Injury Fall to State Agency
Penalty
Summary
The facility failed to report a resident's fall that resulted in a major injury to the State Agency as required. The resident involved had a history of hemiplegia and hemiparesis following a stroke, insomnia, delusions, major depressive disorder, a displaced closed fracture, and a history of falls. The resident required substantial assistance for activities of daily living and had a care plan directing staff to use a gait belt and provide two-person assistance for transfers. Despite these directives, the resident experienced a fall during a transfer when only one CNA assisted, and a gait belt was not used. Following the fall, the resident complained of pain and was later transported to the hospital, where a hip fracture was diagnosed and surgical intervention was performed. Documentation in the electronic medical record indicated that the resident had expressed pain and discomfort after the fall, and the incident was discussed by the interdisciplinary team. The CNA involved reported feeling pressured by the resident to proceed with the transfer alone and acknowledged not following the required protocol for assistance. Despite the severity of the injury and the circumstances of the fall, administrative staff did not report the incident to the State Agency. The rationale provided was that the resident was able to communicate what had happened and initially reported only mild pain, with the extent of the injury not becoming apparent until the following day. The facility's policy required prompt investigation and reporting of accidents and incidents, but this protocol was not followed in this case.
Failure to Provide Bed Hold Notices and Written Transfer Notifications
Penalty
Summary
The facility failed to provide required documentation and notifications related to bed-hold policies and transfer notifications for two residents who were hospitalized. For one resident with multiple chronic conditions, including COPD, respiratory failure, diabetes, anxiety disorder, and congestive heart failure, the facility did not provide a Bed Hold Notice to the resident or her representative upon transfer and admission to the hospital on two separate occasions. The resident's medical record and care plan indicated significant dependence on staff for daily activities and medication management, but there was no documentation that the bed hold policy or notice was given at the time of her hospitalizations. Another resident, who had severe cognitive impairment, multiple sclerosis, seizures, respiratory failure, pneumonia, pressure ulcers, and required a G-tube and supplemental oxygen, was transferred multiple times to an acute hospital with a return anticipated. The facility failed to provide the required written notification of transfer to this resident or his representative for each of these facility-initiated discharges. The resident's records documented repeated unplanned discharges and re-entries, but there was no evidence that the mandated notifications were provided as required by policy. Interviews with administrative staff confirmed that the facility had not been consistently providing bed hold notices or written notifications of transfer as required. The facility's own policies stated that residents and their representatives should be informed of the bed hold policy prior to transfer and receive written notification of transfer or discharge, but these procedures were not followed in the cases reviewed.
Failure to Develop and Implement Comprehensive ADL Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with multiple complex medical conditions, including hypertension, a history of stroke, tracheostomy, and gastrostomy status. The resident's medical record and assessments indicated a need for partial to moderate assistance with activities of daily living (ADLs) such as toileting, bathing, and personal hygiene, as well as decreased functional abilities due to impaired strength and mobility. However, the care plan only included directions for medication administration and communication during care, lacking specific staff instructions for ADL care and functional assistance. Interviews with staff revealed that certified nurse aides did not have access to the care plan and relied on nurses to communicate any special instructions. Administrative staff reported that interventions following incidents such as falls were discussed in meetings and added to the care plan, but there was no evidence that comprehensive, measurable objectives and time frames for ADL support were included for this resident. The facility's policy required individualized, person-centered care plans with measurable objectives and time frames, but this was not followed for the resident in question.
Failure to Revise Care Plan After Multiple Falls
Penalty
Summary
The facility failed to revise the comprehensive care plan to include appropriate interventions for falls for a resident with a significant history of falls and multiple complex medical conditions. The resident's diagnoses included overactive bladder, psychotic disorder, substance dependence, delusional disorders, major depressive disorder, epilepsy, mood affective disorder, anxiety, hypertension, lack of coordination, muscle weakness, repeated falls, cognitive communication deficit, reduced mobility, flaccid hemiplegia, pain, and vascular dementia. The resident had severely impaired cognition, required substantial to maximum assistance with activities of daily living, and was frequently incontinent. The Minimum Data Set documented that the resident had experienced a fall with injury. Despite multiple documented falls, including incidents where the resident was found on the floor in his room, sometimes unable to recall the event or how he ended up on the floor, the care plan was not consistently updated to include new interventions after each fall. In several instances, the event notes specifically stated that the care plan lacked an intervention for the fall. Only after one fall was an intervention (placement of nonskid strips) documented, but subsequent falls did not result in additional care plan updates. Staff interviews revealed that nurses were expected to add interventions to the care plan after each fall, and that interventions were communicated during staff huddles. However, a CNA reported not having access to the care plan and relied on nurses for special instructions. The facility's policy required an individualized, comprehensive, person-centered care plan with measurable objectives and time frames to address each resident's needs. However, the care plan for this resident did not reflect timely or consistent updates following each fall event, as required by policy. This lack of care plan revision following repeated falls constituted a deficiency in the facility's care planning process.
Failure to Provide Restorative Range of Motion Services
Penalty
Summary
A resident with a history of stroke resulting in hemiparesis, along with other medical conditions such as seizures, hypertension, and major depressive disorder, was identified as having limited physical mobility and functional limitations. The resident's care plan documented the need to maintain or improve mobility and prevent complications related to immobility, including contractures. Despite these documented needs, the resident did not receive any physical or occupational therapy, and there was no evidence of restorative range of motion (ROM) exercises being provided. The resident reported never having received ROM exercises or therapy since admission and expressed a desire for such interventions to prevent contractures. Observations confirmed that the resident's affected limb was not being actively exercised, and interviews with nursing staff and administration revealed that the facility did not have a restorative aide or an active restorative therapy program at the time. Staff indicated that exercises would typically be directed by the therapy department, but no such services were in place. The facility's own policy required that residents with limited ROM receive appropriate treatment and services, but this was not implemented for the resident in question.
Failure to Include Census on Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that the daily posted nurse staffing data included the facility census, as required. During a review of daily posted staffing sheets covering the period from January 1, 2024, to March 31, 2025, it was found that the census number was missing from all reviewed postings. The facility had a census of 37 residents at the time of the survey, and a sample of 12 residents was included in the review. Administrative staff confirmed that the staffing coordinator was responsible for posting the daily staffing sheet and acknowledged that the census number had not been included on these postings until the issue was recently identified.
Failure to Ensure Effective Communication and Documentation with Hospice Providers
Penalty
Summary
The facility failed to implement an effective communication process between the facility and the hospice provider for residents receiving hospice services. For one resident with multiple diagnoses including cerebrovascular accident, respiratory failure, congestive heart failure, diabetes, and major depressive disorder, the care plan documented the need for palliative care and outlined general care goals. However, the care plan did not include evidence of collaboration or communication with the hospice provider. Staff interviews revealed uncertainty about the contents of hospice binders, the process for obtaining supplies, and the accessibility of care plans, indicating a lack of clear procedures for documenting and sharing hospice-related information. Another resident with diagnoses of congestive heart failure, COPD, depression, and hypertension had a hospice care plan that directed staff to adjust care according to the resident's changing abilities and to work cooperatively with the hospice team. Despite this, the care plan lacked essential details such as hospice contact information, visit frequency, supplies and medications provided by hospice, and any durable medical equipment. The resident's hospice order and plan of care were available in the facility, but staff interviews again highlighted gaps in knowledge about the communication process and access to relevant information. The facility's policy allowed for contracting hospice services and outlined the need for coordination and communication, but in practice, there was no documented process ensuring that information was consistently shared and accessible to all staff. This deficiency was observed through record reviews, staff interviews, and direct observation, and affected at least two residents who were receiving hospice care.
Failure to Maintain Resident Dignity During Verbal Altercation
Penalty
Summary
The facility failed to uphold the dignity and respect of a resident, identified as R1, who was admitted with a diagnosis of encephalopathy, cognitive communication deficit, amnesia, and acute kidney failure. R1 exhibited moderate cognitive impairment and had a history of verbal aggression and refusal of care. On the day of the incident, R1 was approached by a CNA for a shower, which R1 refused. Later, in the dining room, R1 made racially derogatory remarks towards CNA O, which led to a verbal altercation between them. CNA O responded to R1's racial slurs by raising her voice and engaging in a loud exchange with R1, which drew the attention of other staff and residents. Despite being advised by Social Services X to remove herself from the situation, CNA O continued to express her frustration loudly, repeating the derogatory term used by R1 multiple times. This incident was witnessed by other staff members, who provided statements about the altercation. The facility's policy on resident rights emphasizes treating residents with dignity and respect, particularly those with cognitive impairments. However, the actions of CNA O in this situation did not align with these guidelines, as she engaged in a confrontation with R1 instead of addressing the behavior professionally. This failure to manage the situation appropriately placed R1 and other residents at risk for impaired dignity and decreased quality of life.
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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 Edwardsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkway Operator Llc | 0 mi | ★★★★★ | 0 | 0 |
| Edwardsville Care And Rehab | 0 mi | ★★★★★ | 2 | 2 |
| Bonner Springs Nursing & Rehab Center | 3.4 mi | ★★★★★ | 0 | 0 |
| Brookdale Rosehill | 5 mi | ★★★★★ | 15 | 0 |
| The Healthcare Resort Of Kansas City | 5.2 mi | ★★★★★ | 32 | 0 |
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