Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Nottingham Health And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found multiple medication and treatment carts unlocked and unattended in hallways, despite containing enteral meds, PRN creams, insulin pens, scheduled meds, and OTC meds. On different units, carts were observed left without staff present while holding resident-specific and general treatment supplies. In interviews, an LN and an administrative nurse acknowledged that carts are required to be locked when out of view or not in use, and facility policy specified that medications must be stored in accordance with state and federal requirements.
A resident with hemiplegia and intact cognition had no documented self-administration of medication assessment in the EMR and no care plan addressing self-medication, yet medications were left at the bedside in a pill cup by a CMA. The resident questioned what the pills were, and an LN, upon entering the room, could only tentatively identify one pill and had to remove the cup to verify with the CMA. The resident reported never being assessed to self-administer medications, while administrative staff later stated that appropriate self-administration should be care planned with a provider order and that medications should not be left at the bedside, contrary to the observed practice and the facility’s own medication administration policy.
A resident with hemiparesis after a stroke, severely impaired cognition (BIMS 0), neuromuscular bladder dysfunction, and unsteadiness on feet required extensive assistance with ADLs and was care planned for fall risk, including having frequently used items within reach and education on call light use. During observation, the resident was found in bed yelling for help to be repositioned while both the portable and cord call lights were out of reach—one on the bedside table and the other wrapped around and caught under the bed. Staff, including a CNA, an LN, and an administrative nurse, acknowledged that at least one call light should always be within easy reach of the resident, and the facility’s falls policy required maintaining an environment free from accident hazards with adequate supervision and assistive devices, which was not met in this situation.
The facility failed to secure hazardous areas, leaving laundry rooms with high-voltage panels and chemicals unlocked, accessible to cognitively impaired residents. Additionally, fall interventions for two residents were not implemented as per their care plans, with wheelchairs placed out of reach, increasing fall risk.
A facility with 74 residents was found to have deficiencies in food storage practices across its four kitchens. Observations revealed issues such as unlabeled and undated food items, an open ice machine with a plastic bowl on top, and opened food exposed to air. These practices were contrary to the facility's Dietary Food Storage policy, which requires labeling and dating of opened food to prevent spoilage and contamination, placing residents at risk for food-borne illness.
The facility failed to follow infection control standards, including enhanced barrier precautions, hand hygiene, and disinfection of shared mechanical lifts. A CNA did not sanitize a Hoyer lift after use and failed to perform hand hygiene before serving drinks. Soiled linens were also improperly handled. Staff interviews confirmed these actions were against the facility's infection control policy, putting residents at risk for infectious diseases.
A resident with heart failure and other conditions was provided personal care with open window blinds, exposing them to the street view. Staff interviews confirmed that blinds should be closed to maintain dignity, aligning with the facility's policy. This oversight risked negative psychosocial outcomes for the resident.
A facility failed to update a resident's care plan to include toileting after meals, despite the resident's risk for falls and a history of hemiparesis, osteoarthritis, and recent femur fracture. The resident was found on the floor after attempting to use the restroom independently, highlighting the omission of this critical intervention. Staff interviews confirmed that care plans should be reviewed and updated to ensure safe care.
A facility failed to consistently perform pre-dialysis assessments for a resident requiring hemodialysis, as outlined in their care plan. Despite having a process in place for communication between shifts and with the dialysis center, records lacked evidence of these assessments on multiple occasions. The resident had a complex medical history, including diabetes, hypertension, and renal failure.
A resident with muscle weakness and mobility issues was provided with side rails without a documented risk assessment or informed consent. The resident injured his elbow on the side rail, and staff interviews revealed inconsistencies in the assessment process. The facility's policy on bed device safety was not followed, compromising the resident's safety.
The facility failed to obtain consents or informed declinations for the PCV20 and influenza vaccinations for a resident. The resident's clinical record lacked documentation of whether these vaccines were offered, given, or declined. Although a declination was provided, it was not clear if it was for the current period. The infection preventionist noted that the facility reviews vaccine consent during care plans but does not require yearly signatures for declinations.
Unlocked and Unattended Medication and Treatment Carts
Penalty
Summary
Surveyors identified a deficiency related to improper storage of medications and biologicals when multiple medication and treatment carts were found unlocked and unattended in facility hallways. During the initial tour on 04/06/26 at 07:50 AM, a treatment cart on Holiday House was observed unlocked and unattended; it contained one resident’s enteral medications, resident supplies, and PRN creams. At 08:10 AM the same day, a treatment cart on another unit was found unlocked and unattended, containing residents’ treatment supplies, PRN creams, and two insulin pens. At 08:20 AM on 04/06/26, a medication cart on that same unit was observed unlocked and unattended in the hallway with three insulins and creams for treatments inside. On 04/07/26 at 07:36 AM, another medication cart on the same unit was again observed unlocked and unattended in the hallway, containing scheduled medications and over-the-counter medications. During interviews, a licensed nurse stated that treatment and medication carts should be locked when out of the nurse’s view, and an administrative nurse confirmed that medication and treatment carts should be locked when not being used. The facility’s Medication Labeling and Storage policy dated 01/30/26 documented that medications would be labeled and stored in accordance with facility requirements and Kansas and Federal laws, including appropriate and safe labeling of medications dispensed to all residents.
Failure to Assess Resident Before Leaving Medications at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to assess a resident for the ability to safely self-administer medications before leaving medications at the bedside unsupervised. The resident had a diagnosis of hemiplegia affecting the left nondominant side and an Annual MDS showing a BIMS score of 15, indicating intact cognition. However, the resident’s EMR contained no Self-Administration of Medications assessment, and the Baseline Care Plan did not address self-medication. Despite this lack of assessment and care plan direction, staff practice resulted in medications being left in the resident’s room. During observation, the resident was noted to have a pill cup with two pills on the bedside table and stated she had a question about what the pills were. When a licensed nurse entered, the resident asked what the pills were; the nurse stated one looked like Tylenol but would need to check on the other pill and then said she needed to ask the CMA who had placed and left the medications in the room. The nurse removed the pills to consult the CMA. The resident reported she had never been assessed to self-administer medications to her recollection. When interviewed, administrative staff stated that residents appropriate for self-administration would be identified in the care plan after provider notification and an order, and also stated that medications should not be left at the bedside, which contrasted with the observed practice and the facility’s own Medication Administration Policy referencing a Self-Administration Policy and Procedure.
Failure to Keep Call Lights Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call lights were within reach, as required to keep the environment free from accident hazards and provide adequate supervision to prevent accidents. The resident had multiple significant diagnoses, including hemiparesis/hemiplegia following a stroke, neuromuscular bladder dysfunction, unsteadiness on feet, and major depressive disorder. A recent MDS documented a BIMS score of zero, indicating severely impaired cognition, and showed the resident required setup or cleanup for eating, substantial/maximal assistance with bathing and oral care, and was dependent on staff for toileting. The MDS also documented impairment of one side of the upper and lower extremities and that the resident had not had any falls since admission. A Falls Care Area assessment documented that the falls CAA triggered due to a fall and medications that could increase fall risk, and that the resident would receive medications as ordered, assistance with ADLs, nonskid footwear, and therapy. The care plan included directions for staff to place frequently used items within reach at night, re-educate the resident on call light use, place nonskid strips around the bed, address fall risk due to unawareness of limitations, and use bolsters on the bed. On the survey date, the resident was observed lying in bed with her upper body and right arm leaning to the right and her legs on the left side of the bed, while she yelled out for help to be repositioned. At that time, her portable box call light was on the bedside table and her cord call light was wrapped around the overhead table and caught under the bed, so neither call light was within her reach. Staff interviews confirmed that the resident’s portable call light should be on the overhead table where she could reach it, and that either the portable or cord call light should always be within reach of the resident. An administrative nurse also stated that residents’ call lights should be placed within their reach. The facility’s Falls policy stated that each resident would receive services and care to ensure the environment remained as free from accident hazards as possible and that each resident would receive adequate supervision and assistive devices to prevent accidents, which was not followed in this instance when the resident’s call lights were not accessible.
Failure to Secure Hazardous Areas and Implement Fall Interventions
Penalty
Summary
The facility failed to secure hazardous areas, such as laundry rooms containing high-voltage circuit panels and cleaning chemicals, which were left unlocked and accessible to nine cognitively impaired, independently mobile residents. This oversight was observed during a walkthrough, where it was noted that the rooms contained unlocked electrical panels and hazardous chemicals, posing a risk of preventable accidents. Despite the facility's policy requiring these areas to be locked and inaccessible to residents, staff did not adhere to these safety protocols, thereby exposing residents to potential harm. Additionally, the facility did not implement appropriate fall interventions for two residents, R43 and R2, who were at risk of falls due to their medical conditions. R43, who had a history of falls and required assistance for transfers, was found with his wheelchair placed out of reach, contrary to his care plan. Staff interviews revealed that the care plan was not followed, as the wheelchair should have been placed next to his bed within reach. This failure to adhere to the care plan increased the risk of falls for R43. Similarly, R2, who had a history of falls and required assistance with activities of daily living, was not provided with the necessary fall interventions as outlined in her care plan. Observations showed that her wheelchair was not placed beside her as required, and staff were not fully aware of the interventions needed to prevent falls. The facility's failure to ensure that R2's fall interventions were followed placed her at risk for falls and related injuries.
Deficiencies in Food Storage Practices
Penalty
Summary
The facility, with a census of 74 residents, was found to have deficiencies in food storage practices during a survey. Observations during the initial tour revealed several issues with food storage across the facility's four kitchens. In the Uptown Bistro storage area, an ice machine was found with its lid open and a plastic bowl sitting on top of the ice, which could lead to contamination. Additionally, a small steam table pan in the freezer contained ground meat in a plastic bag that was neither labeled nor dated. Other items, such as a bag of mixed vegetables and a bag of frozen cookie dough, were found opened to air and undated in the freezer. Further observations in the [NAME]/[NAME] house pantry showed a bag of flour on the shelf that was opened and not dated, along with bags of lime gelatin, packets of au gratin cheese mix, bags of pasta, and boxes of cream of wheat, all without dates. In the [NAME]/[NAME] hallway refrigerator, bags of sliced turkey and ham were undated. In [NAME]'s kitchen, a box of egg whites was open to air with no label or date, and small bags of tomatoes, cabbage, and onions were in the vegetable container without labels and dates. Dietary staff confirmed that foods should be labeled and dated as soon as they are opened, as per the facility's Dietary Food Storage policy. The failure to adhere to these standards placed residents at risk for food-borne illness due to potential contamination and spoilage.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to sanitary infection control standards, particularly concerning enhanced barrier precautions, hand hygiene, and the disinfection of shared mechanical lifts. Observations revealed that a Certified Nurse Aide (CNA) pushed a Hoyer lift out of a resident's room without sanitizing it. Additionally, soiled linens were found on the floor of another resident's room. Another CNA was observed exiting a resident's room with a Hoyer lift while wearing an enhanced barrier precaution gown, which was discarded without sanitizing the lift. This CNA also failed to perform hand hygiene after handling the lift and before serving drinks to residents. Interviews with staff, including a Licensed Nurse and an Administrative Nurse, confirmed that the facility's infection control policy required hand hygiene between resident care and when visibly soiled, as well as the cleaning and sanitization of shared equipment like the Hoyer lift. The policy also mandated the proper handling of soiled linens. Despite these guidelines, the facility's practices did not align with the infection control standards, placing residents at risk for infectious diseases.
Failure to Ensure Resident Dignity During Personal Care
Penalty
Summary
The facility failed to ensure a resident's right to dignity and respect during personal care. The incident involved a resident with a history of heart failure, hypertension, and peripheral vascular disease, who required assistance with dressing. Despite the resident's cognitive status being documented as moderately impaired to intact, staff provided personal care with the window blinds open, exposing the resident to the view of the side street. This action was observed when a Certified Nurse Aide and a Certified Medication Aide transferred the resident using a mechanical lift and assisted with dressing while the blinds remained open. Interviews with facility staff, including a Certified Medication Aide, a Licensed Nurse, and an Administrative Nurse, confirmed that the window blinds should be closed during personal care to maintain resident dignity. The facility's Right to Dignity policy, reviewed earlier in the year, emphasized the importance of providing care that promotes respect and dignity. The failure to close the blinds during personal care placed the resident at risk for negative psychosocial outcomes and decreased dignity.
Failure to Update Care Plan for Toileting Needs
Penalty
Summary
The facility failed to revise the care plan for Resident 44 to include toileting needs after meals, despite this intervention being discussed in an interdisciplinary team note. Resident 44, who has a medical history including hemiparesis, osteoarthritis, anxiety disorder, cerebral infarction, and a recent femur fracture, was identified as being at risk for falls. The resident's Minimum Data Set (MDS) indicated mild cognitive impairment and frequent incontinence, requiring substantial assistance with activities of daily living. Despite these needs, the care plan did not reflect the necessary toileting intervention after meals, which was identified as a preventive measure following a fall incident. The deficiency was highlighted when Resident 44 was found on the floor after attempting to use the restroom independently, indicating a lack of communication and implementation of the discussed care plan changes. The facility's policy required ongoing assessments to ensure care plans accurately reflect residents' needs, but this was not adhered to in Resident 44's case. Interviews with staff confirmed that care plans should be reviewed and updated to include all necessary interventions, yet the omission of the toileting after meals intervention placed the resident at risk for further accidents and falls.
Failure to Perform Pre-Dialysis Assessments
Penalty
Summary
The facility failed to consistently perform and communicate pre-dialysis assessments for a resident, identified as R7, who required hemodialysis due to end-stage renal failure. R7's medical history included diabetes mellitus, hypertension, renal failure, epilepsy, cognitive communication deficit, and protein calorie malnutrition. The care plan for R7 required nursing staff to communicate the resident's condition with the dialysis center using a written communication form for each visit. However, the clinical record review revealed a lack of evidence for pre-hemodialysis assessments on multiple specified dates. Interviews with facility staff, including a Licensed Nurse and an Administrative Nurse, indicated that the process involved the night shift nurse filling out a pre-assessment with vital signs and medications, which was then sent with the resident to the dialysis center. Upon the resident's return, the afternoon nurse was responsible for documenting any new orders and conducting a post-assessment. Despite this process, the facility's records did not consistently reflect the completion of pre-dialysis assessments, as required by the facility's Hemo-Dialysis policy, which emphasized accurate and consistent communication to maintain medical management and coordination of care.
Failure to Document Side Rail Assessment and Consent
Penalty
Summary
The facility failed to ensure that a resident, identified as R60, had a documented risk assessment for the use of side rails, consent for their use, and failed to inform the resident or their representative of the associated risks and benefits. R60's electronic medical record indicated diagnoses of generalized muscle weakness, need for assistance with personal care, difficulty with walking, and hypertension. Despite these conditions, there was no evidence of a safety assessment for side rails prior to their installation. The facility provided a side rail assessment with handwritten information, but it was not found in the resident's clinical record during the survey. Additionally, R60 experienced an injury when he hit his right elbow on the small side rail of his bed while trying to reach his phone, resulting in swelling and pain. Interviews with staff revealed inconsistencies in the process of assessing and installing side rails. A Licensed Nurse stated she had never completed a side rail assessment, and the decision for side rail installation was made by the Director of Nursing. The facility's policy indicated that bed devices should be assessed for need and safety, but this was not adhered to, placing R60 at risk for uninformed decisions and impaired safety.
Failure to Obtain Vaccination Consents for a Resident
Penalty
Summary
The facility failed to offer and obtain consents or informed declinations for the Pneumococcal Conjugate Vaccine (PCV20) and influenza vaccination for a resident identified as R17. R17 was admitted on an unspecified date, and a review of their clinical record showed a lack of documentation indicating whether the PCV20 vaccine or the influenza vaccine for the last flu season was offered, given, or declined. Although the facility provided a declination dated 10/06/22, it was not clear if this was for the current vaccination period. Administrative Nurse E, the infection preventionist, stated that the facility reviews vaccine consent during care plans but does not require residents or their representatives to sign yearly for declinations. The facility's Immunization Policy, dated 01/31/24, acknowledges the importance of vaccines in reducing healthcare costs and preventing illness, hospitalization, and death. However, the failure to obtain the necessary consents or declinations for R17 placed the resident at increased risk for acquiring, transmitting, or experiencing complications from pneumococcal disease or influenza.
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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 Olathe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colonial Village | 0.8 mi | ★★★★★ | 0 | 0 |
| Stratford Commons Rehab & Health Care Center | 1.8 mi | ★★★★★ | 21 | 1 |
| Villa St Francis Catholic Care Center Inc | 1.9 mi | ★★★★★ | 0 | 0 |
| The Plaza Health Services At Santa Marta | 2.4 mi | ★★★★★ | 13 | 0 |
| Aberdeen Village | 3 mi | ★★★★★ | 7 | 0 |
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