Stratford Commons Rehab & Health Care Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
resident, staff notified police. Administrative Nurse D stated she believed the facility staff handled Resident 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 Resident 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 Resident R1 and maintained constant communication with the police. Administrative Staff A stated multiple staff members drove around and kept searching for Resident R1. She stated she received report Resident R1 had wandered in the facility during the two days he was admitted to the facility. She stated Resident 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 Resident 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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Stratford Commons Rehab & Health Care Center in OVERLAND PARK, KS inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in OVERLAND PARK, KS, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Stratford Commons Rehab & Health Care Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.