Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

THE VILLAGE AT MISSION

PRAIRIE VILLAGE, KS · 60 certified beds · Last Life Safety survey October 25, 2023

CMS Certification Number 175499 · first certified June 2007

Ownership

Operated by TUTERA SENIOR LIVING & HEALTH CARE · For profit - Limited Liability company

Ownership changed June 1, 2021 (change of ownership)from HCP PRAIRIE VILLAGE KS OPCO LLC

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within KS

44 citations — more than 91% of the 296 certified nursing homes in KS. Compared within KS rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 13 citations; the earlier surveys in the window averaged 15.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (June 2025 to August 2025), and past the point by which nine in ten KS facilities have been surveyed. This facility’s last Life Safety survey was October 2023. Facilities in KS are typically surveyed 20–22 months after the last one (median 21), measured over 298 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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6 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

4 of the 44 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 44 Life Safety citations above. The Physical Environment Index

F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in KS, and nationally. Surveyors differ markedly between states, so the KS figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	44
Median facility in KS	27
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
July 30, 2020	11
February 17, 2022	20
October 25, 2023	13

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0712	Have simulated fire drills held at unexpected times.	3	2023-10-25
K-0920	Ensure proper usage of power strips and extension cords.	3	2023-10-25
K-0511	Have properly installed electrical wiring and gas equipment.	3	2023-10-25
K-0131	Meet requirements for sections of health care facilities separated by fire resistive construction.	3	2023-10-25
K-0353	Inspect, test, and maintain automatic sprinkler systems.	2	2023-10-25
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	2	2023-10-25
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	2	2023-10-25
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	2	2023-10-25

What the citations cover

Citations by CMS category

Smoke Deficiencies 13
Gas, Vacuum, and Electrical Systems Deficiencies 8
Miscellaneous Deficiencies 7
Egress Deficiencies 4
Other 12

Citations by CMS category
Category	Citations
Smoke Deficiencies	13
Gas, Vacuum, and Electrical Systems Deficiencies	8
Miscellaneous Deficiencies	7
Egress Deficiencies	4
Construction Deficiencies	4
Emergency Preparedness Deficiencies	4
Services Deficiencies	4

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

October 25, 2023 — 13 citations

Citations issued on October 25, 2023
Tag	What the surveyor checks	Status
K-0111	Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.	Deficient, Provider has date of correction (January 9, 2024)
K-0131	Meet requirements for sections of health care facilities separated by fire resistive construction.	Deficient, Provider has date of correction (January 9, 2024)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (January 9, 2024)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (January 9, 2024)
K-0347	Properly provide smoke detection systems in areas open to corridors.	Deficient, Provider has date of correction (January 9, 2024)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (January 9, 2024)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (January 9, 2024)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (January 9, 2024)
K-0753	Have restrictions on the use of highly flammable decorations.	Deficient, Provider has date of correction (January 9, 2024)
K-0902	Meet requirements for the installation and maintenance of medical gas and medical vacuum systems.	Deficient, Provider has date of correction (January 9, 2024)
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	Deficient, Provider has date of correction (January 9, 2024)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (January 9, 2024)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (January 9, 2024)

February 17, 2022 — 20 citations

Citations issued on February 17, 2022
Tag	What the surveyor checks	Status
E-0001	Establish an Emergency Preparedness Program (EP).	Deficient, Provider has date of correction (April 30, 2022)
E-0013	Develop Emergency Preparedness policies and procedures.	Deficient, Provider has date of correction (April 30, 2022)
E-0029	Develop a communication plan.	Deficient, Provider has date of correction (April 30, 2022)
E-0036	Establish emergency prep training and testing.	Deficient, Provider has date of correction (April 30, 2022)
K-0131	Meet requirements for sections of health care facilities separated by fire resistive construction.	Waiver has been granted (April 30, 2022)
K-0222	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.	Deficient, Provider has date of correction (April 30, 2022)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Waiver has been granted (April 30, 2022)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (April 30, 2022)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (April 30, 2022)
K-0344	Have an alternate power supply for its alarm system.	Deficient, Provider has date of correction (April 30, 2022)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (April 30, 2022)
K-0346	Follow proper procedures when the fire alarm was out of service for more than 4 hours.	Deficient, Provider has date of correction (April 30, 2022)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Waiver has been granted (April 30, 2022)
K-0354	Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.	Deficient, Provider has date of correction (April 30, 2022)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (April 30, 2022)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (April 30, 2022)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (April 30, 2022)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (April 30, 2022)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (April 30, 2022)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (April 30, 2022)

July 30, 2020 — 11 citations

Citations issued on July 30, 2020
Tag	What the surveyor checks	Status
K-0131	Meet requirements for sections of health care facilities separated by fire resistive construction.	Deficient, Provider has date of correction (March 27, 2020)
K-0222	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.	Deficient, Provider has date of correction (March 27, 2020)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (March 27, 2020)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (March 27, 2020)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (March 27, 2020)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (March 27, 2020)
K-0711	Provide a written emergency evacuation plan.	Deficient, Provider has date of correction (March 27, 2020)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (March 27, 2020)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (March 27, 2020)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (March 27, 2020)
K-0926	Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.	Deficient, Provider has date of correction (March 27, 2020)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.