Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Seasons Rehab And Healthcare Center during CMS and state inspections, most recent first.
Administration failed to ensure secure, individual computer access for medication administration, resulting in a CMT repeatedly using an LPN’s login to access the MAR/TAR and document medications for residents. Despite written policies prohibiting password sharing and falsifying records, the CMT reported ongoing inability to log in under CMT credentials while still being scheduled to pass medications, and instead documented under the LPN’s name, including for controlled substances. HR managed credential setup and password resets and had instructed the CMT not to use another staff member’s sign-in but was unaware the problem persisted; the DON and Administrator also reported they were not aware the CMT was using another staff member’s login. The LPN, who had gone PRN and had not worked for an extended period, denied giving permission or login information and described computers that often remained logged in or displayed passwords, while leadership and the Regional Nurse confirmed that each staff member should have their own sign-in and that staff should not work if unable to chart.
A CMT repeatedly used an LPN’s electronic login to document medication administration for multiple residents with complex conditions, including dementia, Alzheimer’s disease, COPD, CKD, HTN, depression, anxiety, hypothyroidism, diabetes, and cerebrovascular disease. The facility’s policy required that the person administering medications document them on the MAR/TAR with their own initials and signature, but MAR/TAR reviews showed medications and treatments recorded under the LPN’s name on numerous occasions when the LPN was not working. The CMT reported ongoing problems accessing the MAR/TAR under CMT credentials and stated that leadership (administrator, HR, DON, ADON) had been informed of the access issues while HR continued to schedule the CMT to pass meds. The CMT stated that, after initially using the LPN’s login during a shared shift, he/she continued to chart under that login, including for controlled substances, resulting in inaccurate documentation of who actually administered medications.
The facility did not post the actual hours worked by RNs, LPNs, CMTs, and CNAs per shift, instead showing staff numbers for a 24-hour period without detailing hours worked per eight-hour shift. This was contrary to the facility's policy, as confirmed by the Staffing Coordinator and Director of Nursing.
The facility failed to provide two residents with the necessary QIO contact information on their NOMNC forms, which are required for appealing the decision to end Medicare Part A coverage. The Social Services Director was unaware of this omission, which affected residents whose services were expected to end in 2024.
The facility failed to provide individualized activities for two residents who did not participate in group activities, resulting in a lack of mental, physical, and psychosocial stimulation. One resident, with dementia, had an outdated care plan and spent significant time in bed without engaging activities. Another resident, with a stroke and dementia, lacked an activities care plan and also spent much time in bed. The facility's activity program policy was not effectively implemented, with limited one-to-one visits and no weekend activities, leading to insufficient engagement for these residents.
A facility failed to document behaviors and develop a care plan for a resident on psychotropic medication. The resident, with dementia, was prescribed Quetiapine Fumarate, but the care plan lacked target behaviors or symptoms justifying its use. The MAR and progress notes were insufficiently detailed, and staff interviews revealed a lack of awareness and documentation regarding the resident's behaviors and mood-related issues.
A resident with Alzheimer's and a history of falls was improperly moved by staff after a fall without a nurse's assessment, leading to a delay in calling EMS. The resident expressed pain, but staff attempted to move them to the dining room, causing further discomfort. The resident was eventually assessed by a nurse and transported to the hospital nearly two hours later for surgery on a broken hip.
Improper Use of Shared Computer Login for Medication Administration and Documentation
Penalty
Summary
Administration failed to safeguard medication administration by not ensuring a Certified Medication Technician (CMT) had a functioning, individual computer sign-in to access the Medication Administration Record (MAR) and Treatment Administration Record (TAR). The facility’s Employee Handbook, acknowledged in writing by both the CMT and a Licensed Practical Nurse (LPN), prohibited sharing passwords and falsifying records or signatures, and required compliance with federal False Claims Act provisions. Despite these policies, the CMT reported ongoing problems signing in under CMT credentials, while still being scheduled to pass medications, and ultimately used the LPN’s login to document medication administration for residents. Human Resources (HR) was responsible for setting up and managing staff computer credentials, including creating sign-ins after background checks and resetting passwords. HR stated that the CMT had been transferred from CNA to CMT credentials and that the CMT’s password had been reset multiple times. HR also reported telling the CMT not to use another staff member’s sign-in, but was not aware the CMT continued to have access issues and was using the LPN’s credentials. The DON stated HR handled credential setup and that staff could contact HR or the DON at any time for sign-in problems, but the DON was unaware the CMT was having ongoing access issues or using another staff member’s sign-in. The Regional Nurse indicated that each staff member should have their own sign-in, staff should not work if they cannot chart, and PRN staff who have not worked in over three months should be made inactive in the system. The CMT stated that the Administrator, HR, DON, and ADON were all informed on several occasions that the CMT could not sign in as a CMT, only as a CNA, yet the CMT continued to be assigned medication-passing shifts. The CMT described working a shift with the LPN during which the CMT could not chart medications, and the LPN allowed use of the LPN’s sign-in to document in residents’ medical records; the CMT then continued to use the LPN’s sign-in after the LPN went PRN, signing out controlled substances in the narcotic book under the CMT’s own name but documenting administration in the MAR under the LPN’s initials. The LPN, who had not worked since going PRN, denied giving the CMT permission or login information and reported that the computer often remained logged in or displayed passwords, and that the LPN was never asked to change a password. The Administrator, DON, HR, and Regional Nurse all reported they were not aware that the CMT was using the LPN’s sign-in to pass and document medications. This situation had the potential to affect all residents in the facility, which had a census of 74.
Improper Medication Documentation Using Another Nurse’s Electronic Login
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications and treatments were documented on the MAR and TAR by the person actually administering them, as required by the facility’s Medication Administration Policy. The policy stated that the licensed nurse or CMT must chart the drug, time administered, and initial his/her name with each medication administration, and that documentation must be completed by the person who administers the drug or treatment. Contrary to this policy, for approximately three months, a CMT used an LPN’s electronic sign-in to document medication administration for multiple residents, resulting in inaccurate attribution of who administered medications and treatments. The residents affected included individuals with multiple chronic and serious conditions such as dementia, Alzheimer’s disease, COPD, chronic kidney disease (various stages), hypertension, hyperlipidemia, major depressive disorder, anxiety, hypothyroidism, chronic pain, neuropathy, peripheral vascular disease, diabetes type II, cerebrovascular disease, stroke, malignant neoplasm of the head/face/neck, diverticulosis, depression, and delusional disorder. These residents were admitted or readmitted on various dates and were receiving ongoing medication and treatment regimens documented in their MARs and TARs. Review of the facility’s MARs and TARs for November 2025, December 2025, and January 2026 showed that medications and treatments were recorded as being administered by the LPN on numerous dates to at least eight sampled residents, even though timecard records showed the LPN had not worked at the facility after a specific date in late November and had gone to PRN status. Interviews and record reviews revealed how the misdocumentation occurred. The CMT reported that after becoming certified in October 2025, he/she had ongoing problems signing into the electronic system as a CMT and could only sign in under CNA credentials, which did not allow access to the MAR/TAR for medication charting. The CMT stated that he/she informed the Administrator, HR, DON, and ADON on several occasions that the sign-in problem persisted, but it was not corrected, and HR continued to schedule the CMT to pass medications. The CMT said that while working a shift with the LPN, he/she was unable to chart medications, and the LPN allowed him/her to use the LPN’s sign-in to document medication administration. The CMT then continued to use the LPN’s sign-in to chart medications after the LPN went PRN, signing out controlled substances in the controlled drug book under his/her own name but documenting administration in the electronic record under the LPN’s initials. HR confirmed that the CMT had an existing sign-in from CNA status, that passwords had been reset multiple times, and that the CMT had stated he/she could use another staff member’s sign-in, which HR said was not permitted. The Administrator stated he/she was not aware the CMT was having sign-in issues or using the LPN’s credentials, and that staff were not to share passwords. The LPN stated he/she was not aware the CMT was using his/her sign-in, did not give permission or share login information, and described that the computer system sometimes remained logged in or displayed passwords and did not require password changes during his/her employment.
Failure to Post Accurate Staffing Hours
Penalty
Summary
The facility failed to post the actual hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Medication Technicians (CMTs), and Certified Nursing Assistants (CNAs) responsible for resident care per shift. Instead, the facility posted the number of staff for a 24-hour period without detailing the hours worked per eight-hour shift. This deficiency was observed in the Staffing Ratio and Census Reports from 12/27/24 to 1/27/25, which did not comply with the facility's policy dated 10/24/2022 that required posting the current date, total number, and actual hours worked by nursing staff per shift. During an interview, the Staffing Coordinator confirmed that the posted staffing sheets only showed the number of nurses, CNAs, and CMTs for a 24-hour period and did not include the hours worked. The Director of Nursing (DON) acknowledged that until 1/28/24, the staffing sheets did not include total hours worked for licensed and unlicensed staff and covered a 24-hour period rather than each eight-hour shift. The DON and the Administrator were responsible for monitoring the posting of staffing, which was displayed at the reception desk and on resident living units at the nurse's stations.
Failure to Provide QIO Contact Information on NOMNC Forms
Penalty
Summary
The facility failed to provide two residents, who were notified that their Medicare Part A coverage would likely end, with the necessary Quality Improvement Organization (QIO) contact information on their Notice of Medicare Non-Coverage (NOMNC) forms. This deficiency affected two residents, one who started services on July 5, 2024, and was expected to end on July 11, 2024, and another whose coverage began on September 3, 2024, and was expected to end on November 26, 2024. In both cases, the NOMNC forms lacked the QIO contact name and toll-free number, which are essential for residents to appeal the decision to end services. The Social Services Director was unaware that the QIO contact information was missing from the NOMNC forms provided to the residents. The facility's Medicare Denial Process policy requires that the NOMNC, Form CMS-10123, be delivered to the resident or their representative at least two calendar days before Medicare-covered services end, including the QIO contact information. The absence of this information on the forms meant that the residents were not fully informed of their rights to appeal the decision to end their Medicare coverage.
Failure to Provide Individualized Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to meet the needs of two residents who did not participate in group activities and relied on staff for mental, physical, and psychosocial stimulation. Resident #49, diagnosed with non-traumatic brain dysfunction and dementia, was severely cognitively impaired and unable to communicate preferences for activities. Despite having an activity care plan initiated, it was not updated to reflect meaningful activities for the resident, who enjoyed walking, people-watching, and listening to music. Observations showed the resident spent significant time in bed without engaging in stimulating activities, and there was no documentation of daily participation in activities. Resident #176, admitted with a primary diagnosis of stroke and dementia, also lacked an activities care plan. The resident's preferences included being outside, listening to music, and being around animals, but these were not reflected in the care plan. Observations indicated the resident spent much time in bed with no activities taking place, and there was no documentation of activities progress notes. Interviews with staff revealed that the resident might engage in activities if offered coffee or snacks, but there was no structured plan to address the resident's needs. The facility's activity program policy aimed to encourage participation and support residents' capabilities, but it failed to implement individualized care plans and document participation effectively. The activity calendars showed limited one-to-one visits and no scheduled activities on weekends, leaving residents without meaningful engagement. Interviews with staff highlighted a lack of activities on resident halls and insufficient documentation of residents' participation, contributing to the deficiency in meeting residents' needs for mental and social stimulation.
Inadequate Documentation and Care Planning for Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately document behaviors and develop a comprehensive care plan for a resident prescribed a psychotropic medication. The resident, diagnosed with dementia, was admitted to the facility and later prescribed Quetiapine Fumarate for mood disorder. However, the care plan did not specify target behaviors or symptoms justifying the use of the psychotropic medication. The facility's Behavior Management policy requires identifying residents whose behaviors may pose a risk, developing individualized care strategies, and ongoing assessment of behavior management programs, including the effectiveness of psychoactive drugs. The resident's Medication Administration Record (MAR) and progress notes lacked detailed documentation of behaviors and the effectiveness of interventions. Although the MAR recorded various behaviors such as hitting, kicking, and refusing care, the progress notes did not provide details on the duration, intensity, or possible causes of these behaviors. Additionally, the interventions' effectiveness was not consistently documented, which is crucial for future care planning and medication adjustments. Interviews with staff revealed a lack of awareness regarding the resident's mood-related behaviors and the absence of detailed documentation in the care plan. The facility's staff, including a CNA, LPN, MDS Coordinator, and the Director of Nursing, acknowledged the need for detailed documentation of behaviors and the inclusion of target behaviors in the care plan. The staff also recognized that psychotropic medications should be related to the resident's diagnosis, behaviors, and symptoms, with regular reviews by the pharmacist and physician. The deficiency highlights the facility's failure to adhere to its behavior management policy and adequately document and address the resident's behavioral needs.
Failure to Properly Assess and Respond to Resident Fall
Penalty
Summary
The facility failed to properly assess a resident who had fallen before moving them and did not call Emergency Medical Services (EMS) in a timely manner. The incident involved a resident with a history of Alzheimer's Disease, dementia, spinal stenosis, and other conditions, who was moderately cognitively impaired and had a history of falls. On the day of the incident, the resident fell while walking to the bathroom and was found by a CNA. The CNA moved the resident to a sitting position on the floor without waiting for a licensed nurse to perform an assessment. Subsequently, additional staff, including a Restorative Aide/CNA, entered the room and assisted the resident into a chair, again without a nurse's assessment. The resident expressed pain in the left leg and shoulder, but staff attempted to move the resident to the dining room, which caused further discomfort. The resident was left sitting in a chair with the door closed, and it was not until much later that a licensed nurse performed a full assessment and called EMS to transport the resident to the hospital. The delay in calling EMS and the improper handling of the resident after the fall were significant issues. The family member of the resident, who had a video camera in the room, was notified of the fall and requested multiple times for the resident to be sent to the hospital. Despite these requests, there was a delay in action, and the resident was not transported to the hospital until nearly two hours after the fall, where they underwent surgery for a broken hip.
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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 Kansas City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| University Health Lakewood Medical Center | 0.5 mi | ★★★★★ | 12 | 0 |
| Wilshire At Lakewood Rehab Center | 1.7 mi | ★★★★★ | 16 | 0 |
| Edgewood Manor Health Care Center | 2.5 mi | ★★★★★ | 6 | 0 |
| Alpine Breeze Health And Wellness | 4 mi | ★★★★★ | 26 | 0 |
| John Knox Village Care Center | 4.3 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.