Inspection Reports for
Avenue 81
8055 Metcalf Ave, Overland Park, KS 66204, United States, KS, 66204
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
67% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
4
3
2
1
0
Occupancy
Latest occupancy rate
82% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 22, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-10-14.
Findings
All deficiencies have been corrected as of the compliance date of 2025-10-16, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 14, 2025
Visit Reason
The document represents the findings of a resurvey with attached complaints at an assisted living facility conducted on 10/14/2025.
Findings
This plan of correction addresses deficiencies identified during the resurvey and complaint investigations linked to the facility.
Inspection Report
Re-Inspection
Census: 45
Deficiencies: 2
Date: Oct 14, 2025
Visit Reason
The visit was a resurvey with attached complaints 196541, 194924, 190804, and 188167 at the assisted living facility Avenue 81.
Findings
The administrator failed to ensure licensed staff documented all incidents, symptoms, and indications of illness or injury for a resident's ongoing skin wound and infection. Additionally, the facility failed to store food items under safe conditions as thawed nutritional shakes lacked date marking.
Deficiencies (2)
KAR 26-41-105(f)(11) Resident Record Documentation of Incidents. Licensed staff failed to document all incidents, symptoms, and actions taken for Resident 2's ongoing skin wound and infection including dates and results.
KAR 26-41-206(e)(1) Facility Food Storage. The facility stored thawed fortified nutritional shakes without date marking in a locked refrigerator within a medication room, failing to ensure safe food storage.
Report Facts
Resident census: 45
Thawed nutritional shakes: 7
Wound size: 13.5
Wound size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Confirmed lack of wound documentation and thaw date on nutritional shakes |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 1, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-04-16.
Findings
All deficiencies have been corrected as of the compliance date of 2024-04-22, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Abbreviated Survey
Census: 42
Deficiencies: 2
Date: Apr 15, 2024
Visit Reason
The inspection was an abbreviated survey conducted in response to complaint #186866 at the facility on 04/15/24 and 04/16/24.
Complaint Details
The survey was complaint-driven based on complaint #186866. The complaint involved issues with the resident's NSA and documentation of incidents related to the elopement device.
Findings
The facility failed to ensure that revisions to a resident's Negotiated Service Agreement (NSA) were provided to the resident's legal representative. Additionally, the facility did not document all incidents related to the removal of an elopement device from the resident's record.
Deficiencies (2)
K.A.R. 26-41-202 (h) NSA Signatures: The administrator failed to ensure revisions on Resident 1's NSA were provided to the legal representative acknowledging removal of the elopement device due to refusal to wear it.
K.A.R. 26-41-105 (f) (11) Resident Record Documentation of Incidents: The administrator failed to ensure Resident 1's record contained documentation of all incidents, including removal of the elopement device, with date, time, actions taken, and results.
Report Facts
Census: 42
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 15, 2024
Visit Reason
The document is a plan of correction responding to an abbreviated survey conducted for complaint #186866 at the facility on April 15 and 16, 2024.
Findings
The plan of correction addresses findings from an abbreviated survey related to complaint #186866 conducted on April 15-16, 2024. Specific deficiencies or findings are not detailed in this document.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 15, 2024
Visit Reason
The document is a plan of correction responding to findings from an abbreviated survey conducted for complaint #186866 on 2024-04-15 and 2024-04-16.
Complaint Details
The visit was complaint-related for complaint #186866.
Findings
The plan of correction addresses citations identified during the abbreviated survey related to the complaint investigation conducted on the specified dates.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 14, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-02-05.
Findings
All deficiencies have been corrected as of the compliance date of 2024-02-22, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 37
Deficiencies: 1
Date: Feb 5, 2024
Visit Reason
The inspection was a licensure resurvey with attached complaint investigations for complaint numbers 185361, 183146, and 182244 conducted on 02/05/2024 and 02/06/2024.
Complaint Details
The inspection included complaint investigations for complaint numbers 185361, 183146, and 182244.
Findings
The facility failed to comply with the department's tuberculosis guidelines for adult care homes. Specifically, required two-step TB testing documentation was missing for five newly hired employees and one resident.
Deficiencies (1)
KAR 26-41-207(c) Infection Control Policies: The facility failed to ensure compliance with tuberculosis guidelines by not documenting required two-step TB testing for five newly hired employees and one resident.
Report Facts
Resident census: 37
Number of employees lacking TB testing documentation: 5
Number of residents sampled: 5
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 5, 2024
Visit Reason
The document is a plan of correction responding to findings from a licensure resurvey conducted on 02/05/24 and 02/06/24, which included attached complaint investigations numbered 185361, 183146, and 182244.
Findings
The plan of correction addresses citations resulting from the licensure resurvey and associated complaints conducted on the specified dates.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 12, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-05-23.
Findings
All deficiencies have been corrected as of the compliance date of 2023-05-31, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 22, 2023
Visit Reason
The document is a plan of correction responding to findings from a licensure resurvey with attached complaints conducted on May 22 and May 23, 2023.
Findings
The plan of correction addresses citations found during the licensure resurvey and related complaints numbered 177846, 176430, 176301, 173778, and 172179.
Inspection Report
Renewal
Census: 26
Deficiencies: 4
Date: May 22, 2023
Visit Reason
The inspection was a licensure resurvey with attached complaints conducted on 05/22/23 and 05/23/23 to assess compliance with regulatory requirements and investigate complaints.
Complaint Details
The inspection included attached complaints #177846, 176430, 176301, 173778, and 172179.
Findings
The facility was found deficient in conducting functional capacity screenings following changes in resident condition, delegation of nursing duties without proper training documentation, failure to comply with tuberculosis testing guidelines for new employees, and maintaining unsecured hazardous items in the secured memory care unit.
Deficiencies (4)
K.A.R. 26-41-201 (c)(2) Functional Capacity Screen Reassessment was not conducted for resident R2 after a change in condition and hospice admission.
K.A.R. 26-41-204 (e) Delegation of Duties: Licensed Nurse failed to provide training and documentation for delegation of dialing an insulin pen to newly hired CMA H.
K.A.R. 26-41-207 (b)(5-6) (c) Infection Control Policies: Facility failed to ensure compliance with tuberculosis testing guidelines for 4 of 5 newly hired employees.
K.A.R. 28-39-254 (a) Construction: Secured memory care unit was not maintained to protect health and safety due to unsecured chemicals, a claw hammer, and an electric power drill found in resident areas.
Report Facts
Census: 26
Number of newly hired employees reviewed: 5
Residents in assisted living: 16
Residents in secured memory care unit: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA H | Certified Medication Aide | Named in finding for lack of delegation training for dialing insulin pen |
| Licensed Nurse A | Licensed Nurse | Named in findings related to delegation duties and TB testing compliance |
| Regional Nurse F | Regional Nurse | Interviewed regarding delegation and TB testing findings |
| Operator E | Interviewed regarding delegation and TB testing findings and secured unit safety | |
| Regional Director G | Regional Director | Interviewed regarding secured memory care unit safety |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 14, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-05-26.
Findings
All deficiencies have been corrected as of the compliance date of 2022-06-08, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 1
Date: May 26, 2022
Visit Reason
The inspection was an abbreviated survey conducted in response to complaints #KS00171453 and #KS00171386 regarding the facility.
Complaint Details
The investigation was triggered by complaints #KS00171453 and #KS00171386. The complaint was substantiated as the facility did not meet documentation requirements for involuntary discharge and physician rationale.
Findings
The facility failed to document the reason for an involuntary discharge in the resident's clinical record, including the physician's rationale and the necessity of the transfer for the health and safety of other residents. The resident's representative was given a 30-day discharge notice due to the facility's inability to provide requested one-on-one care.
Deficiencies (1)
KAR 26-39-102(e)(2)(A)(C) Admission, Transfer, Discharge: The facility failed to document in the resident's clinical record the reason for involuntary discharge, the physician's substantiation, and the necessity of the transfer for resident welfare and safety of others.
Report Facts
Resident census: 27
Discharge notice period: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse C | Provided multiple nursing progress notes documenting resident behaviors and care events. | |
| Administrative Nurse A | Interviewed regarding discharge notice delivery and documentation. | |
| Administrative Staff B | Interviewed regarding discharge notice delivery and resident representative communication. | |
| Advanced Practice Registered Nurse D | APRN | Interviewed regarding resident's discharge from care and lack of rationale for facility discharge. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 25, 2022
Visit Reason
The document is a plan of correction responding to findings from an abbreviated survey conducted for complaints #KS00171453 and #KS00171386 at the facility on May 25-26, 2022.
Complaint Details
The visit was complaint-related, involving complaints #KS00171453 and #KS00171386. No substantiation status is provided in this document.
Findings
The plan of correction addresses citations resulting from an abbreviated complaint survey conducted at the facility. Specific deficiencies or findings are not detailed in this document.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Sep 7, 2021
Visit Reason
An initial survey was conducted at the assisted living facility to assess compliance and licensing status.
Findings
The survey resulted in a finding of no deficiency citations at the facility.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046107 POC 3BHY11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for a healthcare facility.
Findings
No specific findings or deficiencies are detailed in this document; it serves as a corrective action plan reference.
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