Average — CMS composite of the measures below.
The next survey window likely opens around October 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 Stratford Commons Rehab & Health Care Center during CMS and state inspections, most recent first.
A resident with intermittent confusion and wandering/exit-seeking behavior eloped after staff lost track of him during the night. He had been seen wandering, entering other residents’ rooms, and could not be re-oriented. Staff searched the building and surrounding area, but law enforcement later found him about a mile away wearing only a hospital gown and no shoes. The South egress door was found unlocked and did not alarm when pushed.
Expired medications, including a heartburn relief liquid antacid, Vitamin D3 soft gels, and vials of Ativan, were found in medication storage areas and carts, verified by a CMA and administrative nurses. These expired drugs were not removed from service as required by facility policy, leaving them accessible for potential administration.
Staff did not consistently wear required gowns and gloves during high-contact care activities for residents on Enhanced Barrier Precautions, including transfers and medication administration for individuals with wounds, catheters, and feeding tubes. This occurred despite clear care plans, physician orders, and available PPE supplies, as confirmed by staff and administrative interviews.
A resident with mild cognitive impairment and multiple care needs was spoken to in a disrespectful manner by a CNA when requesting assistance, including being told that staff did not like her because she needed frequent bathroom help. This led to the resident feeling like a burden and experiencing emotional distress. The incident was documented in the grievance log, and the resident council reported concerns about bullying and lack of follow-up discussion with the resident.
A resident with a documented DNR order was given CPR after being found unresponsive because staff did not verify her code status in the EMR, instead relying on a nursing report sheet that incorrectly listed her as full code. Staff interviews confirmed that procedures required checking the care plan or orders for code status, but this was not done in the incident.
A resident with severe cognitive impairment and a diagnosis of neurocognitive disorder with Lewy bodies was administered quetiapine, an antipsychotic, without a documented physician rationale or approved indication. Facility records and medication monitoring lacked evidence of abnormal behaviors or justification for the medication, and psychiatry had not assessed the resident, resulting in noncompliance with facility policy on psychotropic medication use.
A resident with pressure ulcers and osteomyelitis did not receive thorough wound assessments, as required documentation of wound characteristics and measurements was incomplete. The gluteal ulcer increased in size without documented physician notification, and staff did not consistently record wound depth or characteristics during care, contrary to facility guidelines.
A resident with cognitive impairment, muscle weakness, and a history of falls did not have the required fall prevention signage in her room, despite care plan instructions. Observations and staff interviews confirmed the absence of the "Call, Don't Fall" sign, which was intended to help prevent self-transferring and falls. This failure to implement documented interventions resulted in a deficiency related to accident prevention and supervision.
A resident with complex medical needs who required dialysis did not have their condition consistently documented and communicated to the dialysis center as required by facility policy and physician orders. Nursing staff failed to complete and send the dialysis communication form on multiple occasions, resulting in incomplete information exchange between the facility and the dialysis provider.
Inadequate supervision allowed a confused resident to elope through an unsecured exit
Penalty
Summary
The facility failed to provide adequate supervision to prevent a newly admitted resident with documented intermittent confusion and exit-seeking/wandering behaviors from leaving the building without staff knowledge. The resident had a diagnosis of hepatic encephalopathy, was documented on admission as alert and oriented to person and place with intermittent confusion, and had an elopement assessment that stated he was not at risk for elopement. His care plan noted an ADL self-care deficit and the need for one staff assist with transfers. On the night of the incident, staff documented that the resident had been wandering, entering other residents’ rooms, urinating on the floor, and could not be re-oriented. Staff also documented that he walked unsteadily, became combative, and repeatedly exited sought throughout the shift. A nurse last saw him between 05:15 AM and 05:30 AM after a CNA redirected him, and shortly afterward staff could not locate him. Staff searched inside the facility, checked rooms, bathrooms, doors, courtyard, therapy rooms, and the perimeter, and then expanded the search outside the building and into the neighborhood while police were notified. The resident remained missing for approximately five and a half hours and was later located by law enforcement about one mile from the facility, wearing only a hospital gown and no shoes in approximately 65-degree weather. The facility also found that the South egress door was not locked and did not alarm when pushed. The resident’s representative stated the resident remained in the hospital afterward and had no injuries from the elopement.
Expired Medications Not Removed from Service
Penalty
Summary
Surveyors observed that the facility failed to remove expired medications from areas where they could potentially be administered to residents. Specifically, two expired medications—a bottle of heartburn relief liquid antacid with an expiration date of 10/2024 and a bottle of Vitamin D3 soft gels expired since April 2023—were found in the Blue Medication cart. Additionally, two vials of Ativan, an antianxiety drug, with an expiration date of 07/2024, were discovered in the Blue medication room's emergency kit box. These findings were verified by a Certified Medication Aide and two administrative nurses, who confirmed the medications were expired and should have been removed from service. The facility's own policy required immediate withdrawal and proper disposal of outdated drugs, but this procedure was not followed, resulting in the continued presence of expired medications in medication storage areas.
Failure to Adhere to Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
Staff failed to follow established infection prevention and control practices related to Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices and wounds. On multiple occasions, certified nurse aides (CNAs) and a licensed nurse (LN) did not wear required gowns while performing high-contact care activities, such as transferring a resident with wounds and a urinary catheter using a total lift, and administering medications through a gastrostomy tube. These actions were observed despite clear physician orders and care plans specifying the use of gowns and gloves for such activities under EBP protocols. The facility's infection control policy required the use of gowns and gloves during high-contact care for residents at increased risk for multidrug-resistant organism (MDRO) transmission, including those with wounds, catheters, nephrostomy tubes, and feeding tubes. Staff and administrative nurses verified that gowns should have been worn during these care activities, and signage and supplies were present at the point of care. The failure to adhere to these precautions was confirmed through direct observation, record review, and staff interviews.
Failure to Ensure Resident Dignity Due to Disrespectful Staff Conduct
Penalty
Summary
Staff failed to ensure a dignified care environment for a resident with diagnoses including depression, anxiety disorder, cognitive communication disorder, muscle weakness, and dysphagia. The resident, who had mild cognitive impairment and required substantial to maximal assistance with activities of daily living, reported that a Certified Nurse's Aide (CNA) spoke to her in a disrespectful manner when she requested assistance. The CNA allegedly told the resident that staff did not like her because she needed to use the bathroom frequently and indicated that staff were upset about her being wet often. This interaction made the resident feel like a burden and caused her emotional distress, as she expressed not wanting to be around people who did not like her. The facility's grievance log documented the resident's complaint about the CNA's conduct, noting that the CNA was repeatedly rude. The resident council also reported concerns about the resident being bullied by the CNA and noted that the facility did not discuss the impact of the incident with the resident. Staff interviews confirmed expectations for respectful treatment of residents and ongoing training on resident rights and dignity. The facility's policy required all residents to be treated in a dignified manner and for staff to receive ongoing education on these topics.
Failure to Honor Resident's DNR Advance Directive
Penalty
Summary
The facility failed to honor a resident's advance directive regarding Do Not Resuscitate (DNR) status. The resident, who had diagnoses including muscle weakness, atrial fibrillation, cognitive communication disorder, heart failure, and peripheral vascular disease, was documented in the electronic medical record (EMR) and care plan as having a DNR order, signed by both the resident and her medical provider. Despite this, when the resident was found unresponsive, staff initiated cardiopulmonary resuscitation (CPR) without verifying her code status in the EMR. The nursing report sheet incorrectly indicated she was a full code, leading staff to begin CPR. Interviews with facility staff revealed that the expectation was for staff to check the care plan or physician's orders for updated advanced directives before initiating emergency interventions. However, in this incident, staff did not verify the resident's DNR status prior to starting CPR. The facility was unable to provide a policy related to advance directives when requested by surveyors. This failure to follow the resident's documented wishes and established procedures resulted in the deficiency.
Antipsychotic Medication Administered Without Proper Indication
Penalty
Summary
The facility failed to ensure that a resident was free from the use of an antipsychotic medication without a proper physician-documented indication. The resident in question had diagnoses of neurocognitive disorder with Lewy bodies and a cognitive communication deficit, with severely impaired cognition and a need for maximum or full staff assistance with activities of daily living. Despite these conditions, the resident was administered quetiapine, an antipsychotic, daily as ordered by the physician for a mood disorder. The care plan included a Black Box Warning for quetiapine, noting increased risk of death in elderly patients with dementia-related psychosis and that the medication was not approved for such use. The facility's policy required that psychotropic medications only be used for specific, documented conditions, and that antipsychotics generally be reserved for certain diagnoses, none of which were present in this case. Record review showed that the resident's electronic medical record and medication administration record lacked documentation of any abnormal behaviors or a written physician rationale for the use of quetiapine without an approved indication. The pharmacist had provided recommendations for the physician to indicate the reason for use, but the physician did not document a rationale. Additionally, psychiatry had not assessed the resident. These actions and omissions resulted in the use of an antipsychotic medication without proper justification, contrary to facility policy and regulatory requirements.
Failure to Thoroughly Assess and Document Pressure Ulcers
Penalty
Summary
The facility failed to thoroughly assess and document the progression of pressure ulcers for a resident diagnosed with osteomyelitis of the sacrococcygeal region, including the sacrum and coccyx. The resident was admitted with pressure ulcers on the left gluteus and right heel, and physician orders directed specific wound care interventions, including the use of heel protectors, a low air loss mattress, and evaluation by a wound care specialist. However, skin assessments lacked complete documentation, such as wound characteristics and depth measurements. Notably, the gluteal pressure ulcer increased significantly in size, but the assessment did not include all required details, and there was no documentation that the physician was informed of this change. During wound care observations, staff performed cleaning and dressing changes but did not consistently measure or document the depth of the wounds as required. The facility's own guidelines specified that wound type, location, stage, measurements, undermining or tunneling, drainage, odor, and assessment of the wound bed and surrounding tissue should be recorded in the electronic medical record. Despite these requirements, documentation was incomplete, and there was a lack of evidence that the physician was notified of the worsening condition, contributing to the deficiency.
Failure to Implement Fall Prevention Interventions for At-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement fall prevention interventions for a resident with multiple risk factors for falls. The resident had diagnoses including depression, anxiety disorder, cognitive communication disorder, muscle weakness, and dysphagia, and was assessed as having mild cognitive impairment with a BIMS score of 12. She required substantial to maximal assistance with activities of daily living and had a history of a non-injury fall since admission. Her care plan specified the need for a "Call, Don't Fall" sign in her room as part of her fall prevention interventions, along with instructions for staff to anticipate her needs and encourage use of the call light before transferring. Despite these documented interventions, observations on two consecutive days revealed that the required fall prevention sign was not present in the resident's room or bathroom. The resident was unable to locate the sign, and staff interviews confirmed that such signs were typically placed by the bed or toilet to prevent self-transferring. The facility's policy required staff to assess and implement interventions to ensure resident safety, and administrative staff confirmed that nurses were responsible for ensuring interventions were in place. The failure to implement the specified fall prevention intervention constituted a deficiency in providing a safe environment and adequate supervision to prevent accidents.
Failure to Ensure Proper Dialysis Communication and Documentation
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care and services consistent with professional standards of practice, specifically regarding communication and collaboration with the dialysis center. The resident had multiple complex medical conditions, including end-stage renal disease, acute osteomyelitis, sepsis, chronic ulcers, diabetes mellitus, anemia, peripheral vascular disease, muscle weakness, and fatigue. The resident was highly dependent on staff for activities of daily living and had ongoing pain, unhealed pressure ulcers, and a surgical wound. The care plan and physician orders required staff to complete and send a dialysis communication sheet with the resident to the dialysis center and ensure it was returned and completed for each visit. Despite these directives, the facility failed to provide the required information on the resident's condition on the dialysis communication form for multiple documented dates. Staff confirmed that they did not complete the necessary sections of the form as required by facility policy and physician orders. The facility's policy specified that the nurse in charge was responsible for initiating and sending the communication form with the resident on dialysis days, but this process was not consistently followed, resulting in incomplete communication between the facility and the dialysis center.
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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) |
|---|---|---|---|---|
| Colonial Village | 1.6 mi | ★★★★★ | 0 | 0 |
| The Plaza Health Services At Santa Marta | 1.6 mi | ★★★★★ | 13 | 0 |
| Nottingham Health And Rehabilitation | 1.8 mi | ★★★★★ | 10 | 0 |
| Delmar Gardens Of Overland Park | 1.9 mi | ★★★★★ | 15 | 0 |
| Villa St Francis Catholic Care Center Inc | 2.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.