Colonial Village
12500 W 137th St, Overland Park, KS 66221
Colonial Village is a nursing home in Overland Park, Kansas. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 2 of 5CMS overall star rating
- 2 of 5CMS health inspection star rating
- 4 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (913) 730-3700
- Last standard health inspection
- October 31, 2024 (2 years ago)
- Certified beds
- 40
- Residents per day, on average
- 36.2
- Ownership type
- For profit - Corporation
- Legal business name
- Ccrc of Overland Park LLC
- Chain
- Pivotal Health Care
- Takes part in
- Medicare and Medicaid
The same number of health citations as the Kansas average (28).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of April 29, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of April 30, 2025
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
10 citations
Health inspection on October 31, 2024
CMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
61 of 296 Kansas homes (21%) got a citation at the actual harm level in 2024.
Citation F0692. Severity G: actual harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on November 21, 2024.
Citation F0730. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Observe each nurse aide's job performance and give regular training.
CMS lists it as corrected on November 21, 2024.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on November 21, 2024.
CMS has cited this home for F0812 2 times since 2023.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on November 21, 2024.
CMS has cited this home for F0880 3 times since 2021.
Citation F0623. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on November 21, 2024.
Citation F0625. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
CMS lists it as corrected on November 21, 2024.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on November 21, 2024.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on November 21, 2024.
CMS has cited this home for F0690 3 times since 2021.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
CMS lists it as corrected on November 21, 2024.
CMS has cited this home for F0758 2 times since 2023.
Citation F0849. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
CMS lists it as corrected on November 21, 2024.
7 citations
Fire safety inspection on October 31, 2024
CMS lists this as a standard inspection.
Citation K0222. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
CMS lists it as corrected on January 6, 2025.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on January 6, 2025.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on January 6, 2025.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on January 6, 2025.
CMS has cited this home for K0761 2 times since 2021.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on January 6, 2025.
CMS has cited this home for K0918 3 times since 2021.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on January 6, 2025.
CMS has cited this home for K0353 3 times since 2021.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on January 6, 2025.
CMS update of October 30, 2024
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
CMS update of July 31, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of January 31, 2024
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of December 21, 2023
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
14 citations
Health inspection on June 8, 2023
CMS lists this as a standard inspection.
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on June 30, 2023.
CMS has cited this home for F0689 2 times since 2021.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS lists it as corrected on June 30, 2023.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on June 30, 2023.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on June 30, 2023.
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on June 30, 2023.
Citation F0604. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
CMS lists it as corrected on June 30, 2023.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on June 30, 2023.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on June 30, 2023.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on June 30, 2023.
CMS has cited this home for F0677 2 times since 2021.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
CMS lists it as corrected on June 30, 2023.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on June 30, 2023.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on June 30, 2023.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
CMS lists it as corrected on June 30, 2023.
Citation F0851. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
CMS lists it as corrected on June 30, 2023.
9 citations
Fire safety inspection on June 8, 2023
CMS lists this as a standard inspection.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on July 28, 2023.
CMS has cited this home for K0345 2 times since 2021.
Citation K0354. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
CMS lists it as corrected on July 28, 2023.
Citation K0914. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on July 28, 2023.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on July 28, 2023.
Citation K0311. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have an enclosure around a vertical opening shaft.
CMS lists it as corrected on July 28, 2023.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on July 28, 2023.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on July 28, 2023.
Citation K0374. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on July 28, 2023.
Citation K0753. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have restrictions on the use of highly flammable decorations.
CMS lists it as corrected on July 28, 2023.
4 citations
Health inspection on November 2, 2021
CMS lists this as a standard inspection.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on November 30, 2021.
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on November 30, 2021.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on November 30, 2021.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on November 30, 2021.
8 citations
Fire safety inspection on November 2, 2021
CMS lists this as a standard inspection.
Citation E0024. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish policies and procedures for volunteers.
CMS lists it as corrected on January 7, 2022.
Citation K0131. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Meet requirements for sections of health care facilities separated by fire resistive construction.
CMS lists it as corrected on January 7, 2022.
Citation K0321. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on January 7, 2022.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on January 7, 2022.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on January 7, 2022.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on January 7, 2022.
Citation K0923. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on January 7, 2022.
Citation K0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on January 7, 2022.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- SCENIC DEVELOPMENT LLCDirect ownership interest · not applicable · since 12/01/2018
- SCENIC HOLDINGS LLCDirect ownership interest · not applicable · since 07/31/2022
- 3RK, LLCIndirect ownership interest · not applicable · since 01/01/2021
- 5 R CATTLE, LLCIndirect ownership interest · not applicable · since 12/01/2018
- CADET INVESTMENT LLCIndirect ownership interest · not applicable · since 12/01/2018
- LMRAY, LLCIndirect ownership interest · not applicable · since 12/01/2018
- POKY - 5R LLCIndirect ownership interest · not applicable · since 07/31/2022
- POKY FEEDERS INCIndirect ownership interest · not applicable · since 12/01/2018
- WSG LLCIndirect ownership interest · not applicable · since 12/01/2018
- ANDERSON, JORDANIndirect ownership interest · not applicable · since 10/01/2021
- ANDERSON, MARLENEIndirect ownership interest · not applicable · since 12/01/2018
- ANDERSON, WAYNEIndirect ownership interest · not applicable · since 12/01/2018
- GULLEDGE, SCOTTIndirect ownership interest · not applicable · since 12/01/2018
- GULLEDGE, TRAVISIndirect ownership interest · not applicable · since 10/01/2021
- HOWARD, STEVENIndirect ownership interest · not applicable · since 12/01/2018
- WOOD, GILBERTIndirect ownership interest · not applicable · since 12/01/2018
- PIVOTAL HEALTH CARE LLCOperational/managerial control · not applicable · since 12/01/2018
- SCENIC DEVELOPMENT LLCOperational/managerial control · not applicable · since 12/01/2018
- ABBY, AMBEROperational/managerial control · not applicable · since 05/02/2026
- ANDERSON, JORDANOperational/managerial control · not applicable · since 01/01/2025
- GULLEDGE, SCOTTOperational/managerial control · not applicable · since 12/01/2018
- GULLEDGE, TRAVISOperational/managerial control · not applicable · since 01/01/2025
- MARTIN, CAROLINEOperational/managerial control · not applicable · since 02/06/2023
- WOOD, GILBERTOperational/managerial control · not applicable · since 12/01/2018
Questions
When was Colonial Village last inspected?
CMS lists October 31, 2024 as the date of its most recent standard health inspection.
How many citations (violations) does Colonial Village have?
CMS lists 28 health citations since November 2, 2021. CMS also calls these deficiencies.
Has Colonial Village been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Colonial Village?
Its CMS overall star rating is 2 of 5.
Is Colonial Village a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.
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