Inspection Reports for Avenue 81
8055 Metcalf Ave, Overland Park, KS 66204, United States, KS, 66204
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 22, 2025, found the facility in compliance with all regulations and no new deficiencies. Prior inspections showed some deficiencies related mainly to documentation of resident care, including incident and symptom recording, and food storage practices. Earlier complaint investigations substantiated issues with updating negotiated service agreements and tuberculosis screening for new employees, as well as securing hazardous items in the memory care unit. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have addressed prior deficiencies promptly, with recent follow-up inspections confirming corrections and no new noncompliance.
Deficiencies (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
Census
Latest occupancy rate
45 residents
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy 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 cited in the prior inspection 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: Deficiencies cited on 2025-10-14 and corrected by 2025-10-16
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 14, 2025
Visit Reason
The document represents the findings of a resurvey with attached complaints numbered 196541, 194924, 190804, and 188167 at an assisted living facility conducted on 10/14/2025.
Complaint Details
The resurvey included attached complaints 196541, 194924, 190804, and 188167.
Findings
This plan of correction addresses the findings from the resurvey and attached complaints conducted on 10/14/2025 at the assisted living facility.
Inspection Report
Re-Inspection
Census: 45
Deficiencies: 2
Date: Oct 14, 2025
Visit Reason
The inspection was a resurvey with attached complaints 196541, 194924, 190804, and 188167 at the assisted living facility Avenue 81.
Complaint Details
The inspection included attached complaints 196541, 194924, 190804, and 188167.
Findings
The facility failed to ensure licensed staff documented all incidents, symptoms, and indications of illness or injury for a resident with an ongoing skin wound and infection. Additionally, the facility failed to store food items under safe conditions, as thawed fortified nutritional shakes lacked date marking.
Deficiencies (2)
Failure to document all incidents, symptoms, and indications of illness or injury including dates, times, actions taken, and results for Resident 2's ongoing skin wound and infection.
Failure to store food items under safe and sanitary conditions; thawed fortified nutritional shakes lacked date marking when thawed.
Report Facts
Census: 45
Number of thawed fortified 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
Follow-Up
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
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 04/15/24 and 04/16/24.
Complaint Details
The visit was complaint-related for complaint #186866.
Findings
The Plan of Correction addresses citations resulting from an abbreviated survey related to complaint #186866 conducted on 04/15/24 and 04/16/24.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 15, 2024
Visit Reason
The document is a plan of correction related to an abbreviated survey conducted for complaint #186866 at the facility on 04/15/24 and 04/16/24.
Complaint Details
Complaint #186866 triggered the abbreviated survey conducted on 04/15/24 and 04/16/24.
Findings
The plan of correction addresses findings from an abbreviated survey conducted in response to a complaint investigation at the facility on the specified dates.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for plan of correction assistance | |
| Mary Tegtmeier | Submitted and modified the plan of correction document |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 2
Date: Apr 15, 2024
Visit Reason
The inspection was conducted as an abbreviated survey in response to complaint #186866 regarding the facility's handling of a resident's negotiated service agreement and documentation.
Complaint Details
The complaint investigation focused on the facility's failure to provide the resident's legal representative with updated negotiated service agreement revisions and lack of documentation in the resident's medical record regarding removal of the elopement device.
Findings
The facility failed to ensure that revisions to Resident 1's negotiated service agreement, specifically the removal of an elopement device, were provided to the resident's legal representative. Additionally, the resident's medical record lacked documentation of incidents related to the removal of the elopement device.
Deficiencies (2)
Failed to ensure subsequent revisions on Resident 1's Negotiated Service Agreement were provided to the resident's legal representative acknowledging removal of the elopement device.
Failed to ensure the resident record contained documentation of all incidents, symptoms, and other indications of illness or injury including date, time, actions taken, and results related to removal of the elopement device.
Report Facts
Census: 42
Complaint Number: 186866
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director B | Interviewed and confirmed Resident 1 refused to wear the elopement device | |
| Resident 1's DPOA | Interviewed and confirmed refusal to wear elopement device and lack of receipt of updated NSA |
Inspection Report
Follow-Up
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.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Census: 37
Deficiencies: 1
Date: Feb 5, 2024
Visit Reason
The inspection was a licensure resurvey with attached complaint investigations (numbers 185361, 183146, and 182244) conducted on 02/05/2024 and 02/06/2024.
Findings
The administrator failed to ensure compliance with the department's tuberculosis guidelines for adult care homes, specifically the required two-step TB testing for newly hired employees and a resident. Personnel records for five newly hired employees lacked evidence of completed TB testing, and one resident's record lacked documentation of the second step of TB testing.
Deficiencies (1)
Failure to ensure compliance with tuberculosis guidelines requiring two-step TB testing for new employees and residents.
Report Facts
Census: 37
Complaints attached: 3
Employees lacking TB testing: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA F | Certified Medication Aide | Employee record lacked evidence of required two-step TB testing |
| CMA G | Certified Medication Aide | Employee record lacked evidence of required two-step TB testing |
| CNA H | Certified Nurse Aide | Employee record lacked evidence of required two-step TB testing |
| CNA I | Certified Nurse Aide | Employee record lacked evidence of required two-step TB testing |
| CNA J | Certified Nurse Aide | Employee record lacked evidence of required two-step TB testing |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 5, 2024
Visit Reason
The document is a plan of correction submitted in response to findings from a licensure resurvey with attached complaint investigations numbered 185361, 183146, and 182244, conducted on February 5 and 6, 2024.
Complaint Details
The plan of correction relates to complaints numbered 185361, 183146, and 182244 attached to the licensure resurvey.
Findings
The plan of correction addresses citations resulting from the licensure resurvey and complaint investigations conducted on the specified dates.
Inspection Report
Follow-Up
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.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 22, 2023
Visit Reason
The document is a plan of correction addressing findings from a licensure resurvey with attached complaints #177846, 176430, 176301, 173778, and 172179 conducted on 05/22/23 and 05/23/23.
Complaint Details
The plan of correction is related to multiple attached complaints with IDs 177846, 176430, 176301, 173778, and 172179.
Findings
The plan of correction corresponds to deficiencies identified during the licensure resurvey and complaint investigations conducted on the specified dates.
Report Facts
Complaint IDs: Complaint numbers referenced in the plan of correction: 177846, 176430, 176301, 173778, 172179
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 4
Date: May 22, 2023
Visit Reason
The inspection was a licensure resurvey combined with complaint investigations for multiple complaint numbers conducted on 05/22/23 and 05/23/23.
Complaint Details
The inspection included attached complaints #177846, 176430, 176301, 173778, and 172179.
Findings
The facility was found deficient in multiple areas including failure to conduct required functional capacity screenings following a resident's change in condition, failure to provide proper delegation training for nursing procedures, noncompliance with tuberculosis screening guidelines for newly hired employees, and failure to secure hazardous chemicals and tools in the secured memory care unit.
Deficiencies (4)
Failure to conduct a Functional Capacity Screening for a resident after a significant change in condition and admission to hospice services.
Failure to ensure licensed nurse provided training and documentation for delegation of nursing procedures not included in the Certified Medication Aide curriculum, specifically dialing an insulin pen for a newly hired employee.
Failure to ensure facility compliance with tuberculosis guidelines for adult care homes for 4 of 5 newly hired employees lacking required two-step TB test documentation within seven days of employment.
Failure to maintain the secured memory care unit to protect health and safety when unsecured chemicals, a claw hammer, and an electric power drill with a bit in place were found accessible during facility tours.
Report Facts
Residents present: 26
Residents in assisted living: 16
Residents in secured memory care: 10
Newly hired employees lacking TB test documentation: 4
Residents marked with insulin injections: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA H | Certified Medication Aide | Newly hired employee lacking signed delegation training for dialing an insulin pen |
| Licensed Nurse A | Licensed Nurse | Failed to perform Functional Capacity Screening for resident R2 and involved in TB test documentation deficiency |
| Regional RN F | Regional Registered Nurse | Interviewed regarding delegation training and TB test documentation deficiencies |
| Operator E | Interviewed regarding delegation training, TB test documentation, and unsecured chemicals/tools | |
| Certified Nurse Aide B | Certified Nurse Aide | Newly hired employee lacking required TB test documentation |
| Certified Nurse Aide D | Certified Nurse Aide | Newly hired employee lacking required TB test documentation |
| Certified Medication Aide C | Certified Medication Aide | Newly hired employee lacking required TB test documentation |
| Regional Director G | Regional Director | Interviewed regarding unsecured chemicals and tools in secured memory care unit |
Inspection Report
Follow-Up
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 cited in the prior inspection were corrected as of 2022-06-08, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: Deficiencies cited on 2022-05-26
Inspection Report
Abbreviated Survey
Census: 27
Deficiencies: 1
Date: May 26, 2022
Visit Reason
The inspection was an abbreviated survey conducted for complaints #KS00171453 and #KS00171386 at the facility.
Complaint Details
The survey was conducted in response to complaints #KS00171453 and #KS00171386. The complaint was substantiated as the facility failed to 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 requested one-on-one care which the facility could not provide, leading to a discharge notice without proper documentation supporting the rationale.
Deficiencies (1)
Failure to document in the resident's clinical record the reason for involuntary discharge, the physician's rationale, and the necessity of the transfer for health and safety of other residents.
Report Facts
Census: 27
Discharge notice period: 30
Discharge date: Jun 2, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse C | Provided multiple nursing progress notes documenting resident behavior and care | |
| Administrative Nurse A | Interviewed regarding discharge notice and documentation | |
| Administrative Staff B | Interviewed regarding discharge notice and documentation | |
| Advanced Practice Registered Nurse D | APRN | Interviewed regarding resident discharge and physician documentation |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 25, 2022
Visit Reason
The document is a plan of correction related to findings from an abbreviated survey conducted for complaints #KS00171453 and #KS00171386 at the facility on 05/25/22 to 05/26/22.
Complaint Details
The survey was conducted for complaints #KS00171453 and #KS00171386.
Findings
The citations represent findings from an abbreviated survey conducted in response to complaints at the facility during the specified dates.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Sep 7, 2021
Visit Reason
An initial survey was conducted at the assisted living facility in Overland Park, KS to assess compliance and licensing status.
Findings
The survey resulted in a finding of no deficiency citations.
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