Stratford Commons Rehab & Health Care Center
STRATFORD COMMONS REHAB & HEALTH CARE CENTER in OVERLAND PARK, KS — inspection on November 18, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
jeopardy to resident health or safety
resident, staff notified police.
Administrative Nurse D stated she believed the facility staff handled R1's situation and notified her when he eloped.On 10/23/25 at 12:52 PM, Administrative Staff A stated on 10/18/25 around 06:00 AM, she received a call that staff could not find R1, and they continued their search for him.
She stated she and Administrative Nurse E arrived at the facility and immediately searched inside and outside of the building.
Administrative Staff A stated she looked at the doors to see which door he would have exited from and found the South egress door unlocked.
She stated she removed all of the keys from the nurse's station and locked a key in a lock box in the medication room that required a code to open it.
Administrative Staff A stated only three people had the code, and the nurse had to call one of them to get the code.
Then the code changed each time staff accessed the box.
She stated on 10/18/25, the facility continued to search for R1 and maintained constant communication with the police.
Administrative Staff A stated multiple staff members drove around and kept searching for R1.
She stated she received report R1 had wandered in the facility during the two days he was admitted to the facility.
She stated R1 was alert and oriented with mild confusion.The facility's Elopement policy, approved September 2025, directed the facility to provide residents at risk for elopement with at least one of the following: door alarms on facility exits, a personal safety device to alert staff when the resident left the building, or staff supervision.
The policy directed at no time shall a personal safety alarm or door alarm be turned off without the continual supervision of the exit.On 10/23/25 at 04:30 PM, Administrative Staff A was presented with the Immediate Jeopardy (IJ) Template and notified the facility failure to provide adequate supervision to prevent the elopement of newly admitted R1 on 10/18/25, constituted immediate jeopardy at F-F689.
The immediate jeopardy at F-F689 also constituted Substandard Quality of Care at 42 CFR 483.25.The facility identified, implemented, and completed the following corrective measures:1.
Administrative Staff A audited all egress doors and found the South egress door unsecured on 10/18/25.2.
The facility conducted an Ad Hoc- Quality Assurance and Performance Improvement (QAPI) meeting on 10/18/25.3.
The facility audited all residents for elopement evaluations on 10/18/25.4.
The facility educated staff on elopements, abuse, neglect, and exploitation (ANE), and egress doors on 10/18/25.5.
Maintenance evaluated and assessed all facility egress doors on 10/18/25.6.
Administrative Staff A removed all alarm door keys and placed them in a lock box in the medication room that required a code from designated staff to open it on 10/18/25.7.
The facility started door audits on 10/18/25 and continued them two to three times daily.8.
The facility conducted an elopement drill on 10/20/25 and scheduled additional elopement drills through January 2026.Due to the facility completion of all corrective actions prior to the onsite visit, the deficient practice was deemed past noncompliance at a scope and severity of a J (isolated, immediate jeopardy).
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