Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Village Shalom Inc during CMS and state inspections, most recent first.
Surveyors observed multiple failures in food storage and handling, including staff not wearing hairnets or beard nets, opened frozen foods not being sealed, labeled, or dated, and improper glove use during food service. A CNA served food without performing hand hygiene and handled plates in a non-sanitary manner, all contrary to facility policy and increasing risk of food-borne illness.
The facility failed to keep oxygen tanks and hazardous chemicals secured in locked areas, leaving them accessible to cognitively impaired, independently mobile residents. A resident with severe cognitive impairment and ADL deficits was left unsupervised during meals in her room, with her call light out of reach, despite care plan requirements for supervision and call light accessibility. Staff interviews confirmed these lapses, and facility policies requiring secure storage and supervision were not followed.
Staff failed to consistently perform hand hygiene before blood glucose checks and IV administration, and did not sanitize a Hoyer lift between residents. Interviews confirmed that while staff were aware of infection control protocols, these were not always followed, resulting in lapses in hand hygiene and equipment sanitation.
A resident with severe cognitive impairment and behavioral challenges was repeatedly found undressed and exposed in his room, visible from the hallway and exterior windows. Staff acknowledged the resident's preference to be without clothing but did not consistently ensure privacy or cover the resident, and the care plan lacked specific interventions addressing these behaviors, resulting in a failure to maintain dignity and respect.
A resident transitioning from Medicare Part A to LTC was not provided with the required CMS SNF ABN and NOMNC forms, despite documentation of discussions about coverage ending and appeal rights. Social services staff confirmed that these forms had not been issued due to a recent staff changeover, in violation of facility policy.
Two residents with dementia received antipsychotic medications without documented physician rationale, risk versus benefit analysis, or evidence of unsuccessful nonpharmacological interventions. Staff and administration were unsure of appropriate indications for these medications, and the facility could not provide required documentation, resulting in the use of unnecessary psychotropic medications.
A resident with severe cognitive impairment and multiple ADL dependencies did not consistently receive required staff assistance and supervision during meals, as specified in her care plan and facility policy. Observations showed that meals and nutritional supplements were left at her bedside without staff present, and her call light was not within reach. Staff interviews confirmed that supervision and assistance were required but not always provided.
A resident with CHF and other comorbidities did not have daily weights recorded on multiple occasions as ordered by the physician, and there was no documentation that the physician was notified when weights were missed. Staff interviews confirmed the expectation to follow such orders, but records showed repeated omissions.
A deficiency was identified when staff did not ensure a low air-loss mattress was set to the correct weight for a resident with severe cognitive impairment and high risk for pressure ulcers. Despite care plans and assessments indicating the need for pressure-reducing interventions, the mattress was repeatedly observed set at 200 lbs, while the resident weighed 122 lbs. Staff interviews confirmed the expectation to check and adjust mattress settings each shift, but this was not done, resulting in noncompliance with the facility's wound management policy.
Two residents with dementia and Alzheimer's disease were prescribed antipsychotic medications for non-approved indications, and the facility did not address the Consultant Pharmacist's recommendations or ensure proper physician documentation for risk versus benefit. Additionally, a resident's as-needed Midodrine was not administered according to physician orders, and the physician was not notified as required. Staff interviews revealed uncertainty about appropriate antipsychotic use and proper documentation procedures.
A resident with multiple diagnoses, including dementia and hypotension, had a physician's order for Midodrine to be administered as needed for low blood pressure. Over a period of more than two months, there were numerous instances where the resident's blood pressure met the criteria for administration, but the medication was only given once and there was no documentation that the physician was notified when it was not administered as ordered. Staff interviews and facility policy confirmed the expectation to follow physician orders and document notifications, but the clinical record did not reflect this.
A resident with multiple medical conditions received Midodrine without staff following the physician-ordered blood pressure parameters, and there was no documentation that the physician was notified when orders were not followed. Nursing staff confirmed the expectation to check vitals and notify the physician as required, but the facility failed to ensure proper administration and documentation.
Medication carts containing treatment supplies and PRN creams were observed left unlocked and unattended, out of the nurse's view. Nursing staff acknowledged that carts should be locked when not directly supervised, in accordance with facility policy and regulatory requirements.
A resident with severe cognitive impairment and risk for malnutrition was ordered to receive a nutritional supplement 30 minutes after meals, but staff repeatedly provided the supplement with the meal instead. Observations showed the supplement was consumed during or before the meal without required staff supervision, contrary to the physician's order and facility policy.
Direct care staff, including CNAs and CMAs, did not complete the required 12 hours of annual in-service education as documented in their credentialing files. Essential training topics such as infection control, HIPAA, resident rights, and abuse prevention were not evidenced as completed. Administrative staff confirmed that the oversight occurred due to a lapse in tracking responsibilities.
Deficient Food Storage and Handling Practices Observed
Penalty
Summary
The facility failed to ensure proper food storage and handling practices in multiple areas, as observed during surveyor visits. Dietary staff were seen in the main kitchen without appropriate hairnets or beard nets, and opened packages of frozen potato products were found in the freezer without being placed in sealed bags, labeled, or dated. In the dining and serving areas, a dietary server wore gloves but did not change them after draining liquid from a bowl of fruit before continuing to serve food. Additionally, a dietary server in a kitchenette was observed serving food without her long hair secured in a hairnet. A Certified Nurse Aide (CNA) assisted with serving prepared plates to residents, handling plates with her thumb on the lip of the plate and failing to perform hand hygiene during the meal service. These actions were not in accordance with the facility's Food Storage- Food Safety & Infection Control policy, which requires all opened food items to be labeled, dated, and properly sealed, and for staff to wear hairnets in food preparation and serving areas. The observed deficiencies placed residents at risk of food-borne illnesses.
Failure to Secure Hazardous Materials and Provide Supervision During Meals
Penalty
Summary
The facility failed to secure pressurized supplemental oxygen tanks and hazardous cleaning chemicals in locked areas, leaving them accessible in unlocked closets within the dining area and adjacent storage spaces. Thirteen fully pressurized oxygen cylinders were observed stored in floor racks in an unlocked supply closet, and unsecured cleaning chemicals labeled as hazardous were found in a nearby storage closet. Staff interviews confirmed that these areas were expected to be locked at all times, but staff sometimes forgot to fully close the doors, resulting in the materials being accessible to residents, including those with cognitive impairments. Additionally, the facility did not provide consistent supervision to a resident with severe cognitive impairment, Alzheimer's disease, and significant ADL deficits during mealtimes. The resident's care plan required staff to supervise her during meals, encourage her to eat in the dining room, and ensure her call light was always within reach. However, multiple observations showed the resident eating alone in her room without staff present, with her call light out of reach under her bed, and her nutritional supplement left with her meal. Staff interviews confirmed that supervision and call light accessibility were required per the care plan, but these interventions were not consistently implemented. Facility policies required hazardous materials and oxygen to be secured and inaccessible to residents, and for residents to have access to a call system at all times. The facility's fall management and call light policies also emphasized the need for supervision and minimizing accident risks, but these were not followed, resulting in residents being exposed to preventable hazards and lacking necessary supervision.
Failure to Perform Hand Hygiene and Sanitize Shared Equipment
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols, specifically regarding hand hygiene and equipment sanitation. A licensed nurse did not perform hand hygiene before preparing a glucometer for a blood glucose check, nor before entering a resident's room or administering IV medication. The nurse also used the same alcohol wipe to clean the glucometer, the resident's finger, and the insulin pen hub, contrary to established procedures. Additionally, a certified nurse's aide did not sanitize a Hoyer lift after use with one resident before making it available for use with others. Staff interviews confirmed awareness of the required hand hygiene and equipment sanitation protocols, but also revealed inconsistent practices, particularly with the Hoyer lift, which was not always sanitized between residents. The facility's own policy, aligned with CDC guidelines, mandates hand hygiene before and after resident contact and after contact with medical equipment, as well as sanitizing shared equipment between uses. These lapses in protocol were observed directly by surveyors and acknowledged by staff during interviews.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
A resident with severe cognitive impairment, Parkinson's Disease, major depressive disorder, muscle weakness, and an overactive bladder was dependent on staff for all activities of daily living, including dressing, personal hygiene, and toileting. The resident exhibited behaviors such as wandering, rejection of care, and undressing, and was noted to have poor judgment, safety awareness, and memory recall. The care plan acknowledged behavioral challenges and refusal of care but did not include specific interventions related to the resident's preference or behaviors regarding undressing. Multiple nursing notes documented incidents where the resident was found naked in his room, either standing in the restroom or lying in bed without clothing or covers, and at times refused staff assistance to redress or provide care. Observations confirmed the resident was left uncovered and visible from the hallway and exterior windows for extended periods. Staff interviews indicated awareness of the resident's preference to be undressed but revealed inconsistent efforts to maintain the resident's dignity by ensuring privacy or covering him. The facility's dignity policy required maintaining each resident's dignity and respect, but the lack of individualized care plan interventions and insufficient measures to prevent exposure led to a failure to provide a dignified care environment.
Failure to Provide Required Medicare/Medicaid Beneficiary Notification Forms
Penalty
Summary
The facility failed to provide required Medicare/Medicaid beneficiary notification forms to a resident whose Medicare Part A coverage was ending and who was transitioning to long-term care. Specifically, the CMS form 10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) and the CMS form 10123 Notice of Medicare Non-Coverage (NOMNC) were not issued to the resident. Documentation in the electronic medical record indicated that staff discussed the end of Medicare coverage, the transition to LTC, and the right to appeal with the resident and their family, but the actual forms were not provided as required. A review of the facility's policy confirmed that residents should be informed in writing about services, charges, and their rights to appeal at least three days prior to a change in payor status or discharge. Social services staff acknowledged that due to a recent staff changeover, the required ABN and NOMNC forms had not been issued to residents as they should have been. This lapse was identified during the survey when the forms could not be produced upon request.
Failure to Document Appropriate Indication and Physician Rationale for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that two residents with dementia diagnoses received antipsychotic medications only with appropriate indications and documented physician rationale. For one resident with moderately impaired cognition and diagnoses including dementia and Alzheimer's disease, the medical record showed ongoing administration of olanzapine for psychosis without documentation of risk versus benefit or evidence of unsuccessful nonpharmacological interventions. The pharmacy consultant had identified and reported irregularities related to the non-approved indication for this antipsychotic use, but the facility was unable to provide the required physician documentation upon request. For another resident with severely impaired cognition and Alzheimer's disease, quetiapine was administered for severe dementia with agitation. The medical record lacked a physician-documented rationale for the continued use of this antipsychotic for dementia-related behaviors, and no documentation of risk versus benefit was available. The care plan referenced attempts at gradual dose reduction and nonpharmacological interventions, but there was no supporting physician documentation for the ongoing use of the medication. Interviews with nursing staff and administration revealed uncertainty regarding appropriate indications for antipsychotic medications and a lack of awareness about the need for physician documentation of risk versus benefit. The facility's policy required monitoring the need for psychotropic medications and evaluating their effectiveness, but these requirements were not met in the cases reviewed, resulting in the administration of unnecessary psychotropic medications without proper justification.
Failure to Provide Consistent Mealtime Assistance and Supervision
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's disease, severe cognitive impairment, and multiple ADL (activities of daily living) dependencies did not receive consistent assistance and supervision during mealtimes. The resident's care plan and assessments specified the need for staff to provide substantial to maximal assistance with eating, supervision during meals, and encouragement to eat in the dining room for proper monitoring. The care plan also instructed that the resident should not be left alone in her room while eating and required staff to provide feeding assistance and cues. Observations revealed that on multiple occasions, the resident was served meals in her room without staff present to assist or supervise her. On two separate mornings, the resident was found in bed with her meal and nutritional supplement left at her bedside, with no evidence of staff assistance. The call light was not within her reach, and staff were not present as she consumed her meal. Only on one occasion was staff observed staying in the room to assist the resident during her meal. Interviews with nursing and aide staff confirmed that facility policy and the resident's care plan required staff to supervise and assist the resident during meals, especially due to her cognitive and communication deficits. Staff acknowledged that the resident should not be left alone to eat in her room and that the call light should be accessible. The facility's policy on activities of daily living also required staff to provide necessary assistance to maintain residents' abilities.
Failure to Follow Physician's Order for Daily Weights in Resident with CHF
Penalty
Summary
The facility failed to follow a physician's order for daily weights for a resident with multiple diagnoses, including congestive heart failure (CHF), diabetes mellitus, peripheral vascular disease, kidney disease, and edema. The resident's care plan required daily weights before breakfast, with instructions to notify the physician if there was a weight gain of more than two pounds in one day or five pounds in one week. Despite these orders, review of the resident's electronic medical record, medication administration record, and treatment administration record revealed that staff did not measure and record the resident's weight on nine specific dates over a 69-day period. There was also no documentation that the physician was notified when the daily weights were not obtained. Interviews with staff confirmed that all staff were responsible for assisting with daily weights if ordered, and that the nurse was responsible for ensuring weights were obtained, recorded, and that the physician was notified as needed. The facility's policy required all medications and treatments to be administered as ordered by a healthcare professional. However, the lack of documentation and failure to follow the physician's order for daily weights constituted a deficiency in providing appropriate treatment and care according to orders, resident preferences, and goals.
Failure to Set Pressure-Reducing Mattress to Resident's Weight
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident's low air-loss mattress, intended to reduce the risk of pressure ulcers, was set within the resident's current weight range as required. The resident, who had diagnoses including Alzheimer's disease, insomnia, anxiety, and speech/language deficits, was severely cognitively impaired and dependent on staff for most activities of daily living. The resident was identified as being at risk for skin breakdown and pressure ulcers, with care plans and assessments indicating the use of pressure-reducing devices and a repositioning program. Despite these interventions, observations over several days revealed that the mattress was consistently set to 200 lbs, while the resident's documented weight was 122 lbs. The care plan lacked specific instructions regarding the correct mattress settings. Interviews with nursing staff and administrative personnel confirmed that the mattress should have been set according to the resident's current weight and that staff were expected to check the settings each shift. The facility's wound management policy required assessment of pressure ulcer risk and implementation of preventative interventions, but the failure to set the mattress appropriately represented a lapse in following these protocols. This inaction placed the resident at risk for complications related to skin breakdown and pressure ulcers.
Failure to Address Pharmacist Recommendations and Inadequate Documentation for Antipsychotic Use
Penalty
Summary
The facility failed to address recommendations made by the Consultant Pharmacist (CP) regarding the medication regimen of two residents with dementia and Alzheimer's disease. For one resident, the CP identified irregularities related to the administration of Midodrine, a medication prescribed for hypotension. Although the resident's blood pressure readings were within the physician-ordered parameters for administration on multiple occasions, the clinical record did not document that the physician was notified when the medication was not administered as ordered. The CP had reported these irregularities in the Monthly Medication Reviews, but there was no evidence that the facility acted on these recommendations or communicated with the physician as required. Additionally, both residents were prescribed antipsychotic medications for non-approved indications, specifically for dementia and Alzheimer's disease. The CP identified and reported these irregularities, noting the lack of appropriate physician documentation for the risk versus benefit analysis and the rationale for continued use of antipsychotics for these diagnoses. The facility was unable to provide documentation supporting the use of these medications for the residents, despite repeated recommendations from the CP. The care plans for both residents indicated monitoring for side effects and collaboration with the physician, but there was no evidence that the required documentation or physician engagement occurred. Interviews with nursing staff and administrative personnel revealed a lack of understanding regarding appropriate indications for antipsychotic medication use. Staff were unsure about the correct process for addressing CP recommendations and for ensuring physician orders were followed and documented. The facility's policies required the CP to review medication regimens monthly and communicate potential or actual problems to the physician and Director of Nursing, but these procedures were not effectively implemented, resulting in the identified deficiencies.
Failure to Administer Hypotension Medication as Ordered and Notify Physician
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician's order for a resident's hypotension medication was properly administered. The resident, who had diagnoses including dementia, tachycardia, hypotension, hemiplegia, and Alzheimer's disease, had a physician's order for Midodrine to be given as needed for low blood pressure, with specific parameters for administration. Review of the electronic medical record showed that, over a 67-day period, there were 50 documented opportunities where the resident's blood pressure met the criteria for administration of Midodrine, but there was no documentation that the physician was notified when the medication was not administered as ordered. The medication was only administered on one occasion during this period, despite multiple qualifying blood pressure readings. Further review of the resident's care plan and psychotropic drug use assessment indicated that the resident was at risk for adverse side effects from medications, and staff were expected to monitor for side effects and notify the physician as needed. Interviews with nursing staff confirmed that the expectation was to follow physician orders and document any notifications to the physician if orders were not followed. However, the clinical record lacked evidence of such notifications, and the facility's policy required all medications to be administered as ordered by a healthcare professional.
Failure to Follow Physician-Ordered Parameters for Midodrine Administration
Penalty
Summary
A deficiency occurred when staff failed to follow physician-ordered parameters for administering Midodrine, a medication used to treat hypotension, to a resident with multiple diagnoses including dementia, tachycardia, hypotension, hemiplegia, and Alzheimer's disease. The physician's order specified that Midodrine should only be administered if the resident's systolic blood pressure was less than 130 mmHg or diastolic blood pressure was less than 60 mmHg, not to exceed three times daily. Review of the resident's electronic medical record and vital signs from March 1 to May 6 showed 50 instances where blood pressure readings met the criteria for administration, but there was no documentation that the physician was notified as required. Additionally, the medication was administered on a date within this period, but the clinical record lacked evidence of proper notification or documentation. Interviews with nursing staff confirmed that the nurse or certified medication aide was responsible for obtaining vital signs before administering medications requiring such checks, and that the nurse should ensure medications are given as ordered. Staff also stated that the physician should be notified if orders are not followed, with documentation in the interdisciplinary notes. The facility's policy required all medications to be administered as ordered by a healthcare professional. The failure to adhere to these protocols resulted in a significant medication error for the resident.
Failure to Secure Medication Carts When Unattended
Penalty
Summary
Surveyors observed that medication carts containing residents' treatment supplies and as-needed (PRN) creams were left unlocked and unattended, specifically noting an instance where a treatment cart was out of the nurse's view on hall 600. A licensed nurse confirmed that the cart should have been locked and secured when staff walked away. Additionally, an administrative nurse stated that the facility's expectation was for medication carts to be locked if not within the nurse's view. The facility's own Medication Labeling and Storage policy required all drugs and biologicals to be stored securely and in accordance with state and federal regulations, but this policy was not followed during the observed incidents.
Failure to Follow Physician's Order for Timed Supplement Administration
Penalty
Summary
A deficiency occurred when staff failed to follow a physician's order regarding the administration of a nutritional supplement for a resident with Alzheimer's disease, severe cognitive impairment, and multiple care needs. The physician's order specified that the resident was to receive one carton of Ensure by mouth 30 minutes after each meal to address protein-calorie malnutrition. However, observations on multiple occasions revealed that the Ensure supplement was provided with the resident's meal rather than 30 minutes after, as ordered. The resident was dependent on staff for most activities of daily living, including eating, and was at risk for malnutrition and weight loss. Documentation in the resident's care plan and assessments indicated the need for supervision and assistance during meals, as well as specific nutritional interventions. Despite these documented needs and orders, staff were observed leaving the supplement with the meal, and the resident consumed the Ensure during or before the meal without staff present to supervise or assist as required. Interviews with nursing and dietary staff confirmed that the expectation was to provide the supplement 30 minutes after meals, in accordance with the physician's order, to encourage meal consumption before supplement intake. The facility's policy also indicated that dietary supplementation should follow the guidance of the medical and dietician team. The failure to adhere to the specified timing of the supplement administration constituted a failure to follow the physician's order and the facility's own policy.
Failure to Provide Required Annual In-Service Training for Direct Care Staff
Penalty
Summary
The facility failed to ensure that direct care staff, including Certified Nurse Aides (CNAs) and Certified Medication Aides (CMAs), received the required 12 hours of annual in-service education and demonstrated competency as mandated by facility policy. Record review revealed that the credentialing files for four staff members lacked evidence of completion of the required yearly training. The missing in-service education included essential topics such as infection control, HIPAA, resident rights, abuse prevention, compliance, emergency preparedness, and behavioral health, among others. During interviews, administrative staff confirmed that the responsibility for tracking and ensuring completion of nurse aide in-services had previously been assigned to the facility scheduler. However, it was discovered that CNAs and CMAs had not completed the necessary annual education hours. The director of nursing (DON) was subsequently identified as the new responsible party for ensuring compliance with training requirements. The facility census at the time was 65 residents.
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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) |
|---|---|---|---|---|
| Brookdale Overland Park | 0.6 mi | ★★★★★ | 11 | 0 |
| Ignite Medical Resort Overland Park Llc | 1.1 mi | ★★★★★ | 1 | 0 |
| Tallgrass Creek, Inc | 2.1 mi | ★★★★★ | 15 | 0 |
| Advanced Health Care Of Overland Park | 2.1 mi | ★★★★★ | 2 | 0 |
| Overland Park Post Acute | 2.5 mi | ★★★★★ | 5 | 0 |
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