Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Hope Care Center during CMS and state inspections, most recent first.
The facility failed to ensure the dish machine was dispensing enough sanitizer to properly clean food prep and service items. Although the dishwasher log showed daily PPM readings of 110 to 70, direct checks by staff and surveyors repeatedly showed chlorine levels below the required 50 PPM, including about 10 PPM and around 40 PPM. A kink was noted in the chemical hose, and the Administrator stated there were no policies for dishwasher maintenance or chemical disinfecting.
Loose hallway handrails outside resident rooms were observed not firmly attached to the wall. Surveyors saw the condition on two occasions, and the MDS said the handrail had not been loose that long while noting a resident used it when leaving the room. The Mnt Sup stated the handrails were checked monthly, and the issue potentially affected at least 4 residents.
Unsafe Furnace Room and Outdoor Exit Discharge Conditions The facility failed to address a black substance on the ceiling of a furnace room and an 8-ft leak of black colored substance from the ceiling to the floor. The Maintenance Director was unsure of the source and stated the area leaked more when it rained. The facility also failed to maintain an outdoor handrail support outside the kitchen in good repair, where crumbling concrete and visible rust were observed at the post. The Administrator stated the concrete needed repair and had been overlooked.
The facility failed to maintain food safety standards, including the absence of a thermometer in a freezer, storing a dented can of baked beans with undented cans, and using a heavily scored cutting board with flaking plastic bits. The Dietary Manager confirmed that damaged foodstuffs are returned to the vendor, and damaged items like cutting boards are discarded.
The facility failed to maintain a comprehensive infection prevention and control program for Legionella and other water-borne pathogens. Observations revealed a lack of a facility-specific risk management plan and incomplete CDC toolkit measures. Interviews indicated that the program was based on regulations but lacked proper documentation and oversight, with occasional undocumented flushings and infrequent water testing.
The facility did not follow its procedures for conducting Criminal Background Checks and checking the Nurse Aide Registry for abuse indicators. Two employees, an LPN and a cook, were hired without these checks. The HR Manager was unaware of the requirement and admitted responsibility for the oversight.
The facility failed to complete annual MDS assessments on time for several residents, with delays ranging from 26 to 196 days. This deficiency was due to staffing issues, including a gap between MDS Coordinators, leading to a backlog in submissions. The current MDS Coordinator is still in training and has not yet caught up with the overdue assessments.
The facility failed to complete quarterly MDS assessments for eight residents, with delays ranging from 2 to 116 days. Staffing issues, including a gap between MDS Coordinators, contributed to the backlog. The DON acknowledged the problem, and the current MDS Coordinator is still in training.
A facility reported a medication error rate of 27.59%, affecting three residents. Errors included improper documentation and administration of medications like Carbidopa-Levodopa and Lorazepam. The DON confirmed discrepancies in medication administration and documentation, with staff failing to adhere to facility policies.
A facility failed to complete a timely Significant Change MDS assessment for a resident admitted to hospice care. The assessment was marked 'In Progress' 44 days after admission, exceeding the 14-day requirement. The LPN responsible was newly hired, and the DON noted ongoing issues with timely MDS assessments due to the previous ADON's departure.
The facility failed to update care plans for two residents as their needs changed. One resident experienced significant weight loss, partly due to medication, which was not reflected in their care plan. Another resident admitted to hospice care had a care plan lacking essential information about hospice services and medication orders. Staff interviews revealed systemic issues in updating care plans, with the MDS Coordinator primarily responsible but not consistently completing updates.
A resident's medical record inaccurately included an antipsychotic medication order due to a failure in transcription and reconciliation processes. Despite the resident's hospice admission orders clearly declining Haloperidol, it was mistakenly added to the Physician Order Sheet. The LPN did not recognize the invalidity of the order, and the DON admitted to not reconciling medications for two months, which should occur monthly.
The facility failed to conduct initial and quarterly smoking assessments for two residents who smoked, as required by their smoking policy. Despite being able to smoke unsupervised, there was no documentation of these assessments in their medical records. Interviews with staff revealed a lack of awareness and oversight in completing and documenting these assessments.
A significant medication error occurred when a resident received Lorazepam twice within one and a half hours due to poor documentation and communication between shifts. The night nurse administered the medication without proper documentation, leading the day shift CMT to unknowingly administer it again. The facility's policy required immediate documentation of medication administration, which was not followed, resulting in this error.
Dish Machine Not Reaching Required Sanitizer Level
Penalty
Summary
The facility failed to ensure appropriate sanitation of dish and cookware when the dish machine was not dispensing an adequate amount of chemicals to sanitize food prep and service items. Review of the facility’s blank Daily Dietary Checklist showed kitchen staff were to record water temperature and sanitizer PPM, and the dishwasher manufacturer’s manual required a minimum of 50 PPM chlorine. However, the facility’s Dish Machine Log for August 2025 documented daily PPM values of 110 to 70, while direct observations on 9/4/2025, 9/5/2025, and 9/8/2025 showed test strips reading approximately 10 PPM, below 50 PPM, and about 40 PPM after repeated runs of the dishwasher. During observation, the Kitchen Manager noted a small kink in the hose near the bucket that fed chemicals to the dishwasher and adjusted the hose before rerunning the machine. The dishwasher continued to test below the required chlorine level on multiple occasions. The Maintenance Director stated he/she used a TDM to measure the dishwasher water and obtained 70 PPM, and the Kitchen Manager later obtained new test strips because he/she was unsure how old the existing strips were. The Administrator stated the facility did not have policies regarding dishwasher maintenance or chemical disinfecting and expected the dishwasher to disinfect dishes properly with the correct PPM.
Loose Hallway Handrails Outside Resident Rooms
Penalty
Summary
Two handrails outside of resident rooms [ROOM NUMBERS] were not firmly attached to the wall. The deficiency was identified during observations on 9/5/24 at 11:38 A.M. and 9/8/25 at 11:17 A.M., when surveyors saw the handrails outside the rooms were loose. During an interview on 9/8/25 at 11:17 A.M., the Maintenance Director stated the handrail had not been loose that long and said a resident from resident room [ROOM NUMBER] used the handrail when leaving the room. During an interview on 9/9/25 at 2:25 P.M., the Maintenance Supervisor stated the handrails were checked once per month. The report states this practice potentially affected at least 4 residents who lived in those rooms, and the facility census was 16 residents.
Unsafe and Poorly Maintained Furnace Room and Outdoor Exit Discharge Areas
Penalty
Summary
The facility failed to prevent the presence of a black substance on the ceiling of Furnace room [ROOM NUMBER] and failed to repair an eight-foot-long area where a black substance leaked from the ceiling to the floor. During observation with the Maintenance Director, several areas of black substance were seen on the ceiling of the furnace room, along with an eight-foot-long leak of black colored substance. In interview, the Maintenance Director stated he/she was not sure of the origin of the black substance on the ceiling and said the area of the black colored leak had additional leaking when it rained. The facility also failed to maintain an outdoor handrail supporting system outside the kitchen in good repair. Observation showed one post of the handrail at the outdoor exit discharge from the service passageway adjacent to the kitchen was set in crumbling concrete, with the crumbled area measuring 8 inches high, 12 inches wide, and 6 inches long, and visible rust on the metal post. In interview, the Administrator stated the concrete was in need of repair and that the area had been overlooked previously. This affected one non-resident use area and at least 7 residents who resided in that area of the facility and used the exit discharge through the service area next to the kitchen.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain food safety standards in several areas, which had the potential to affect all residents, visitors, volunteers, and staff consuming food from the kitchen. During an inspection, it was observed that there was no thermometer in the freezer located in the Food Storage room, which is necessary to confirm adequate temperature ranges. Additionally, a 7-pound 3-ounce can of baked beans was found dented and stored alongside undented cans, which is against food safety regulations. Furthermore, a heavily scored yellow cutting board was observed in the kitchen, with plastic bits flaking off, posing a risk of cross-contamination. In an interview, the Dietary Manager acknowledged that damaged foodstuffs are separated and returned to the vendor for a refund, and that food should be free of foreign substances. The manager also stated that damaged food preparation items, such as cutting boards, are discarded when found, and confirmed that all refrigerators and freezers should have thermometers.
Inadequate Infection Prevention and Control Program for Water-Borne Pathogens
Penalty
Summary
The facility failed to establish and maintain a comprehensive infection prevention and control program to prevent the development and transmission of Legionella and other water-borne pathogens. During the survey, it was observed that the facility lacked a facility-specific risk management plan assessment in accordance with the ASHRAE industry standard #188. Additionally, there was no completed CDC toolkit with control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. The facility's Water Management Program binder contained blank log sheets and checklists that were not used, and there was no documentation of any site log book being maintained for cleanings, sanitizings, descalings, and inspections. Interviews with the Maintenance Manager and the Administrator revealed that the water-borne pathogen program was based on regulations and created by the Maintenance Manager and the previous Administrator. The Maintenance Manager admitted that the blank sheets in the binder were not used and that the company responsible for the program only tested the water for Legionella once a year, considering the facility to be at low risk. Occasional flushings were performed but not documented. The Administrator expected that the program creator would be aware of all requirements, indicating a lack of oversight and accountability in the program's implementation.
Failure to Conduct Required Background Checks
Penalty
Summary
The facility failed to adhere to its policies and procedures for conducting Criminal Background Checks (CBC) and checking the Nurse Aide Registry for federal indicators of abuse, as required by state regulations. This deficiency was identified during a review of employee records, where it was found that two out of four sampled employees did not have the necessary Nurse Aide Registry checks completed. Specifically, an LPN hired in February and a cook hired in April did not have these checks documented. During an interview, the Human Resource Manager admitted to being unaware of the requirement to complete the nurse aide registry checks for all employees and acknowledged responsibility for conducting background checks.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete the annual comprehensive Minimum Data Set (MDS) assessments in a timely manner for several residents, as required by federal regulations. Specifically, the assessments for four sampled residents and one supplemental resident were overdue by varying durations, ranging from 26 to 196 days. For instance, one resident's last annual assessment was due on May 3, 2024, but was 26 days overdue, while another resident's assessment was 196 days overdue. These delays in completing the MDS assessments were identified through interviews and record reviews, highlighting a significant lapse in the facility's compliance with mandated assessment schedules. The deficiency was attributed to staffing issues, as the facility's former MDS Coordinator was not full-time, and there was a gap between their departure and the hiring of a new coordinator. During this period, the submission of MDS assessments fell behind. The current MDS Coordinator is still in training and has not yet managed to address the backlog. Interviews with facility staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed awareness of the problem and the expectation for timely completion and submission of MDS assessments.
Failure to Complete Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Sets (MDS) were completed quarterly for eight residents out of a sample of eight, with a total facility census of 13 residents. The MDS is a federally mandated assessment tool used for care planning. The report highlights that several residents had overdue MDS assessments, with delays ranging from 2 to 116 days. For instance, Resident #3's quarterly assessment was 63 days overdue, while Resident #59's assessment was 116 days overdue. These delays indicate a systemic issue in the timely completion of MDS assessments, which are crucial for updating care plans based on residents' changing needs. Interviews with facility staff revealed that the former MDS Coordinator was not full-time, and there was a gap between their departure and the hiring of a new coordinator, during which the MDS submissions fell behind. The current MDS Coordinator is still in training and has not yet managed to catch up with the backlog. The Director of Nursing acknowledged the problem and stated that MDS assessments should be completed and submitted on time, every three months as scheduled. The LPN interviewed mentioned that changes in residents' care needs are typically communicated to the MDS Coordinator for updates, but this process was disrupted due to staffing issues.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 27.59% during the survey. This deficiency affected three residents, with errors occurring during medication administration. The facility's policy required medications to be administered per physician orders and documented immediately after administration. However, discrepancies in medication administration and documentation were observed, leading to multiple errors. For Resident #160, there was confusion regarding the administration of Carbidopa-Levodopa and Lorazepam. The Certified Medication Technician (CMT) A administered Lorazepam without proper documentation and incorrectly documented the administration of Carbidopa-Levodopa. The Licensed Practical Nurse (LPN) B had already documented the administration of Lorazepam earlier, resulting in a double dose within a short timeframe. The Director of Nursing (DON) confirmed the errors in documentation and administration. Resident #4's medications, including Metoprolol, Gabapentin, and Cyclobenzaprine, were not administered as per the MAR, despite CMT A's assumption that they had been given by the night shift. Similarly, Resident #2 declined medications, stating they had already been received, yet CMT A documented them as administered. The DON acknowledged that night shift staff might administer some day shift medications but expected proper documentation and adherence to administration times.
Failure to Complete Timely Significant Change MDS Assessment for Hospice Admission
Penalty
Summary
The facility failed to complete a necessary Significant Change Minimum Data Set (MDS) assessment for a resident who was admitted to hospice care. The resident was admitted to Hospice A, and the physician's order for hospice admission was placed but not entered timely into the resident's medical record. The last completed MDS assessment for the resident was a Quarterly Assessment, and the Significant Change Assessment was marked as 'In Progress' with an Assessment Reference Date (ARD) set 44 days after the hospice admission, which exceeded the 14-day requirement as per the MDS 3.0 Resident Assessment Instrument (RAI) Manual. Interviews revealed that the Licensed Practical Nurse (LPN) responsible for completing MDS assessments was recently hired and acknowledged that the Significant Change Assessment was overdue. The Director of Nursing (DON) indicated that the responsibility for the assessment lay with the previous Assistant Director of Nursing (ADON), who no longer worked at the facility. The DON also noted that MDS assessments had been an ongoing issue, with the past ADON failing to complete them timely, and expected assessments to be completed within the timeframe specified by the RAI Manual.
Failure to Update Care Plans for Changing Resident Needs
Penalty
Summary
The facility failed to update care plans as residents' needs changed, affecting two residents. Resident #59 experienced significant weight loss over several months, which was not reflected in their care plan. Despite being on a regular diet and having dentures adjusted, the resident continued to lose weight, partly due to self-initiated efforts and medication side effects. The care plan did not document the resident's weight loss goals, nutritional interventions, or the impact of medication on weight loss. Resident #161 was admitted to hospice care, but their care plan lacked essential information. The care plan did not include details about the resident's hospice admission, medication orders, or the services provided by the hospice agency. There was no guidance for staff on administering PRN oxygen or monitoring the effects of prescribed medications like Morphine and Lorazepam. Interviews with facility staff revealed systemic issues in updating care plans. The MDS Coordinator was primarily responsible for care plan updates, but these were not consistently completed. The Director of Nursing acknowledged that care plans were overdue and that nurses could update them as needed, but this was not the practice followed. The lack of timely updates to care plans contributed to the deficiencies identified.
Failure to Accurately Transcribe and Reconcile Medication Orders
Penalty
Summary
The facility failed to accurately transcribe and reconcile medication orders, leading to an antipsychotic medication being added to a resident's medical record without a valid order. The resident, who had diagnoses including seizures, dementia, adjustment disorder, stroke, and insomnia, was admitted to hospice services with specific instructions to decline the use of Haloperidol, an antipsychotic drug. Despite these instructions, the medication was incorrectly entered into the resident's Physician Order Sheet (POS) and remained there without an end date, although it was never administered to the resident. Interviews revealed that the Licensed Practical Nurse (LPN) responsible for inputting the orders did not recognize the invalidity of the Haloperidol order, which was marked as declined. The Director of Nursing (DON) confirmed that the orders were verified but acknowledged that medication reconciliation had not been performed in the previous two months, contrary to the standard practice of monthly reconciliation. The DON also noted that the Haloperidol order should have been discontinued after 14 days, as per standard practice for antipsychotic drugs.
Failure to Conduct Smoking Assessments for Residents
Penalty
Summary
The facility failed to complete initial and quarterly smoking assessments for two residents who smoked, out of a total of nine residents who smoked in the facility. The facility's smoking policy required these assessments to establish a resident's capacity for smoking, determine necessary assistance, and ensure safe smoking habits. However, there was no documentation of these assessments in the electronic medical records for the two residents, despite their care plans indicating they smoked and could do so unsupervised. Resident #3 was admitted with diagnoses including glaucoma, high blood pressure, heart disease, paraplegia, pain, and edema. The resident was alert and oriented, required assistance with certain activities, and was able to smoke unsupervised. Despite these details in the care plan, there was no record of any smoking assessments being completed for this resident. Similarly, Resident #59, who was independent in daily activities and smoked unsupervised, also lacked documentation of smoking assessments in their medical record. Interviews with facility staff, including an LPN and the DON, revealed that smoking assessments were supposed to be completed and documented in the electronic medical record system. However, the DON acknowledged that these assessments were not being done appropriately, and there was a lack of awareness that the assessments were not populating in the system. This oversight led to the deficiency in ensuring the safety and supervision of residents who smoked.
Significant Medication Error Due to Poor Documentation and Communication
Penalty
Summary
The facility failed to ensure medications were administered without significant errors, as evidenced by the administration of Lorazepam, a controlled medication for anxiety, twice within one and a half hours to a resident. The incident involved a Certified Medication Technician (CMT) and a Licensed Practical Nurse (LPN) who both administered Lorazepam to the same resident within a short timeframe. The CMT administered Lorazepam at 7:30 A.M., unaware that the LPN had already given the medication at 6:14 A.M. This error was compounded by the lack of proper documentation and communication between the night and day shifts, leading to confusion about which medications had been administered. The facility's policy required medications to be administered per physician orders and documented immediately after administration. However, the night nurse often administered day shift medications without documenting them, leaving the day shift staff to guess which medications had been given. This practice led to the CMT assuming that all morning medications had been administered when they were not documented. The Director of Nursing acknowledged that night shift staff might administer some day shift medications but expected proper documentation to prevent such errors. The failure to document and communicate effectively resulted in the resident receiving Lorazepam twice within a short period, highlighting a significant medication administration error.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 837 citations issued within 25 miles in the last 12 months — including the 25 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kansas City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Armour Oaks Senior Living Community | 0.4 mi | ★★★★★ | 19 | 1 |
| Rehab Of Kansas City South | 0.5 mi | ★★★★★ | 2 | 0 |
| Highland Rehabilitation & Health Care Center | 1.9 mi | ★★★★★ | 4 | 0 |
| Kingswood Senior Living | 2.1 mi | ★★★★★ | 0 | 0 |
| Claridge Court | 2.2 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Hope Care Center.
100% money-back within 48 hours.
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.