Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Garden Terrace At Overland Park during CMS and state inspections, most recent first.
A facility failed to provide adequate supervision when two residents with Alzheimer’s disease and dementia exited after a door alarm sounded. A CNA reset the alarm without checking the door, and staff did not realize the residents were missing for about 45 minutes until a community member called from a nearby store and returned them in her car.
A resident with dementia and multiple behavioral health diagnoses experienced escalating aggression, wandering, and self-harm statements. The facility did not adequately assess or document behavioral triggers, failed to update the care plan with individualized interventions, and often did not notify the provider or representative of significant behavioral changes. Staff interventions were frequently ineffective, and the resident's behaviors continued to escalate, resulting in harm and eventual hospital transfer.
A resident with dementia and mental health diagnoses exhibited escalating aggression, suicidal ideation, and behavioral disturbances, especially after medication changes. Despite repeated documentation of these behaviors in the EMR, there was no evidence that the provider was notified as required by facility policy, resulting in a lack of timely intervention until the resident required emergency transfer.
Failure to Prevent Resident-to-Resident Physical Abuse: A cognitively impaired resident with a history of aggression, wandering into peers’ rooms, and wanting to fight assaulted two other residents after a brief lapse in supervision. One resident was found bleeding in the dining area, and the same resident then entered another resident’s room and punched him while he was in bed. Both residents required emergency hospital transfer, with one admitted for a subdural hematoma and the other for facial injuries and a subdural hematoma with mid-line shift.
Multiple residents with severe cognitive impairment were observed undressed or exposed in public or semi-public areas, and staff provided care or moved residents without seeking their permission or engaging with them. Staff also failed to manage resident interactions during meals in a way that preserved dignity, and did not follow the facility's own behavioral health policy emphasizing individualized, respectful care.
Several residents were administered antipsychotic medications without appropriate clinical indications, risk versus benefit documentation, or recent attempts at gradual dose reduction. Staff interviews revealed uncertainty about proper indications for these medications, and consultant pharmacist reviews lacked recommendations for continued use. Facility policy required thorough documentation and regular evaluation, but these steps were not consistently followed.
Multiple residents with dementia and high fall risk experienced preventable accidents and injuries due to staff failing to keep call lights within reach, improper use of mechanical lifts, lack of supervision during transfers, and allowing access to bed controls. These actions and inactions were contrary to the facility's own care plans and fall management policies.
Multiple residents with dementia and cognitive impairments exhibited ongoing behaviors such as aggression, wandering, and entering peers' rooms, while staff interventions were limited and care plans lacked individualized, person-centered strategies. Staff often relied on redirection, which was frequently ineffective, and there was no facility policy on dementia care available when requested. These deficiencies resulted in repeated incidents affecting residents' dignity and quality of life.
Two residents with dementia were administered antipsychotic medications without appropriate indications, and the consultant pharmacist did not identify or report these irregularities or recommend gradual dose reductions as required. Nursing staff were unclear about proper indications and the process for acting on pharmacy reviews, and the physician did not document risk versus benefit for continued antipsychotic use. Facility policies requiring documentation and interdisciplinary review were not followed, resulting in continued unnecessary medication administration.
Several residents did not have documentation showing that the PCV20 vaccine was offered, administered, or declined, and staff interviews revealed uncertainty and inconsistency in tracking and offering the vaccine. Facility records lacked evidence of PCV20 consent, declination, or historical administration, despite policy requirements.
Nursing staff removed food items from a resident's meal trays without physician authorization, despite care plan and dietary orders specifying her diet. Staff cited concerns about blood glucose but did not follow proper procedures, leading to the resident attempting to retrieve the removed food. Facility policy and administrative staff confirmed that such removal was not permitted.
A resident with severe cognitive impairment and total care needs sustained a head laceration during staff-assisted transfer. Staff failed to immediately notify the physician or document the incident at the time of injury, resulting in delayed medical evaluation and treatment. The deficiency was due to lack of timely communication and adherence to facility protocols.
A resident who completed therapy and was discharged home did not receive the required CMS Notification of Medicare Non-Coverage (NOMNC) form at the end of a Medicare Part A episode. Staff interviews confirmed the facility's practice of not issuing NOMNC notices to residents discharged home with Medicare A days remaining, contrary to policy.
Two residents did not have comprehensive, person-centered care plans addressing their specific needs. One resident's care plan lacked instructions for daily shaving preferences, resulting in inconsistent personal hygiene, while another resident's plan omitted details for oxygen therapy and BiPAP use, leading to uncertainty among staff about respiratory care. Staff interviews and observations confirmed these omissions and a lack of clear communication regarding individualized care.
A resident with a history of stroke, hemiplegia, and severe cognitive impairment exhibited ongoing verbal and physical aggression toward staff during ADLs, transfers, and medication administration. Despite repeated incidents, including staff injuries and skin tears, the care plan was not updated to include additional person-centered interventions, and staff expressed uncertainty about available strategies beyond reapproaching the resident.
A resident with severe cognitive impairment and physical limitations did not receive daily assistance with shaving as preferred, resulting in several days of facial hair growth. Staff provided shaving only on scheduled shower days and were unaware of the resident's daily preference, which was not documented in the care plan. Facility policy required respect for resident dignity and individual choices.
A resident with severe cognitive impairment and multiple comorbidities, including edema managed by diuretic therapy, was repeatedly observed without TED hose in the mornings despite physician orders and care plan directives. Nursing staff interviews revealed unclear responsibility for ensuring the application of TED hose, resulting in the resident not receiving the prescribed treatment.
Two residents with significant risk factors for pressure ulcers, including one with dementia and diabetes and another with a history of cellulitis and existing pressure ulcers, were observed in bed without their physician-ordered heel protectors or suspension boots in place. Staff interviews confirmed that the devices were not always applied as ordered, and that both nurses and CNAs were responsible for ensuring their use. This failure to follow orders and facility policy placed the residents at increased risk for pressure ulcer development.
A resident with dementia and multiple physical impairments, who was fully dependent on staff for care, did not have prescribed knee extension braces applied as required by the care plan. Despite clear documentation and no record of refusal, staff failed to ensure the braces were used, as confirmed by multiple observations and staff interviews.
A resident with an indwelling catheter and severe cognitive impairment was observed with a visibly full catheter bag and tubing on multiple occasions, with staff failing to empty the bag as required by physician orders and facility policy. Staff interviews confirmed that the bag should be emptied at least every shift and as needed to prevent urine backflow and infection, but the care plan lacked specific instructions for emptying frequency.
A resident with dementia, CHF, and hypoxia did not have a documented physician order with dosing instructions for oxygen therapy, and the care plan lacked direction for oxygen and BiPAP use. Observations showed oxygen tubing in use and left unbagged on a dining table. Staff confirmed that equipment should be stored in a sanitary manner and that respiratory care should be included in the care plan.
A resident sustained two separate head injuries while under the care of a CNA who lacked appropriate competencies, including improper use of a mechanical lift and failure to seek assistance during care. Both incidents resulted in lacerations requiring sutures, with delayed nursing assessment and notification to the medical provider, and incomplete documentation of the events.
Two residents received medications without required monitoring or complete orders. For one resident, staff did not obtain or record blood pressure and pulse prior to administering a beta-blocker as ordered, and a topical pain medication order lacked a specified dosage. Staff interviews confirmed these omissions, and facility policy required adherence to prescriber orders and proper documentation.
Two residents with severe cognitive impairment and terminal diagnoses were receiving hospice care, but their facility care plans did not include specific directions for staff collaboration with hospice providers, such as contact information, services, equipment, or visit frequency. Staff confirmed that hospice information was kept in a separate binder and not integrated into the facility's care plans, contrary to facility policy, resulting in a lack of coordinated care.
A resident with severe cognitive impairment and a history of aggressive behavior was physically abused by a CNA after the resident hit the CNA. The incident occurred when the CNA told the resident they could not have sugar due to diabetes, leading to an argument. The CNA retaliated by punching the resident, resulting in a bruise and pain. The facility's failure to follow the resident's care plan and manage the situation appropriately led to the abuse.
A cognitively impaired resident with a history of expressing a desire to leave eloped from the facility due to inadequate supervision. The resident was found outside in high temperatures after exiting through a stairwell door with a disabled alarm. Despite previous behaviors indicating a risk, the resident's elopement risk was not properly assessed or addressed in the care plan.
The facility failed to provide appropriate dementia care for a resident with severe cognitive impairment and Parkinson's disease. Staff did not consistently follow the resident's care plan, leading to incidents of inappropriate handling and language. This inconsistency affected the resident's well-being.
A facility failed to provide necessary assistive care and services for a resident with multiple fractures and dementia, leading to improper handling of weight-bearing restrictions and inconsistent ADL assistance. This resulted in the resident experiencing pain and potential risk of injury due to lapses in communication and documentation among staff.
Failure to Respond to Door Alarm Allowed Two Cognitively Impaired Residents to Elope
Penalty
Summary
The facility failed to provide adequate supervision and failed to ensure staff responded appropriately to a door alarm, which allowed two cognitively impaired residents to exit the facility without staff knowledge or supervision. Around 4:30 PM, the two residents left the dining room together and proceeded out of the facility. One nurse told them she would see them for dinner, and they walked out after agreeing. A CNA heard a door alarm and reset it without checking what triggered it. One resident had diagnoses of Alzheimer’s disease and dementia, a BIMS score of 3, and a care plan identifying her as at risk for elopement due to cognitive decline. The other resident also had diagnoses of Alzheimer’s disease and dementia, a BIMS score of 4, and documentation stating she required 24-hour care for safety and well-being. Both residents had care plans identifying them as elopement risks and noting interventions such as inclusion in the elopement book and provision for safe wandering. The facility did not realize the residents were out of the building for approximately 45 minutes. A community member later called the facility from a store down the street and reported that she had the two residents with her. The community member stated the residents had been with her at the store since about 4:30 PM to 4:45 PM and brought them back to the facility in her personal vehicle. Staff then assessed the residents and found no injuries or pain. The facility’s investigation documented that the residents exited through the lobby area after the alarm sounded, and staff interviews confirmed that the alarm was silenced without checking the door area to determine who had triggered it.
Failure to Provide Individualized Dementia Care and Behavioral Management
Penalty
Summary
The facility failed to provide appropriate dementia care and services to a resident diagnosed with vascular dementia, cognitive communication deficit, major depressive disorder, and anxiety disorder. The resident exhibited ongoing and escalating behaviors, including aggression towards staff and other residents, wandering, and verbalizations of self-harm and suicidal ideation. Despite these behaviors, the facility did not adequately assess, identify, record, or respond to the resident's specific behavioral triggers, nor did they reassess and update the care plan with individualized interventions tailored to the resident's needs. The care plan lacked resident-specific strategies for managing behaviors and triggers, and staff interventions were often ineffective. Documentation in the resident's medical record revealed multiple instances where the resident displayed aggressive and unsafe behaviors, such as attempting to strike staff, refusing care, wandering, and making statements about wanting to die. Staff frequently attempted verbal redirection, which was documented as ineffective in many cases. There were also several occasions where the facility failed to notify the resident's provider or representative of significant behavioral changes, including suicidal statements and increased agitation following medication changes. The facility's own policy required individualized, person-centered care plans and prompt notification of changes in condition, but these were not consistently followed. Interviews with staff confirmed that the care plan did not include resident-specific interventions for dementia and that triggers for behaviors were not identified. Staff reported increased behavioral issues after medication changes, including aggression and sleep disturbances, but provider notifications were not always documented or made. The facility's deficient practice resulted in ongoing harm, as the resident's behaviors escalated without effective intervention, ultimately leading to the resident's transfer to the hospital for further evaluation and care.
Failure to Notify Provider of Resident's Escalating Behaviors and Suicidal Statements
Penalty
Summary
The facility failed to notify a resident's provider of new or escalating behaviors, as required by policy. The resident in question had a history of vascular dementia, cognitive communication deficit, major depressive disorder, and anxiety disorder, and was admitted to the facility before being transferred to the hospital. The resident exhibited significant behavioral symptoms, including aggression, wandering, restlessness, physical aggression towards staff and other residents, suicidal and death statements, and increased agitation, particularly following the discontinuation of certain medications. Despite these behaviors being documented in the electronic medical record (EMR), there was no evidence that the provider was notified of these incidents over multiple periods. The care plan for the resident lacked individualized interventions related to the resident's specific behaviors and triggers. Multiple behavior notes documented incidents such as aggression, attempts to strike or bite staff, suicidal ideation, and increased fall risk. These behaviors were observed and recorded by staff, but the medical record did not show that the provider was informed of these significant changes or incidents, including after medication changes that appeared to exacerbate the resident's symptoms. Interviews with nursing staff confirmed that provider notification was expected in such cases, but documentation of such notifications was absent during critical periods. The facility's policy required immediate notification of the resident, physician, and representative when there was a significant change in the resident's physical, mental, or psychosocial status. However, the provider was not notified of the resident's escalating behaviors, suicidal statements, or increased agitation and aggression, particularly after medication adjustments. This lack of timely communication with the provider persisted until the resident's condition deteriorated to the point of requiring emergency intervention and hospital transfer.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect cognitively impaired residents from resident-to-resident physical abuse when one resident assaulted two other residents in the secured unit. The resident who initiated the assaults had Alzheimer’s disease, a BIMS score of 5 indicating severe cognitive impairment, a documented history of physical aggression, wandering into peers’ rooms, and behaviors including wanting to fight. His care plan noted behavioral concerns and included supervision and redirection measures, and records also showed he had been placed on one-to-one supervision on the day of the incident. On the morning of the event, a CNA briefly left the dining area unsupervised to assist another staff member. When the CNA returned, one resident was found bleeding from the face while the aggressive resident stood nearby with blood on his hands, and blood was observed on the window, table, and floor. The CNA asked whether he had hit the resident, and he admitted that he had. After being told to walk away, he left the area and entered another resident’s room, where he began punching that resident while the resident was lying in bed. Both assaulted residents required emergency hospital transfer. One resident was admitted with a subdural hematoma, and the other was admitted with facial lacerations and later documented as having a subdural hematoma with a six-millimeter mid-line shift. Witness statements described the aggressive resident repeatedly hitting one resident with closed fists and having to be physically removed from the other resident’s room. The facility’s records also noted prior behaviors, including unpredictable mood changes, extreme statements about wanting to fight, and going into peers’ rooms and taking items.
Failure to Ensure Resident Dignity and Respect in Care Environment
Penalty
Summary
The facility failed to maintain a dignified care environment for several residents, as evidenced by multiple observations of residents with severe cognitive impairment being exposed or undressed in public or semi-public areas. One resident was repeatedly observed with her pants and briefs pulled down and touching the inside of her briefs in a room near the dining area, rather than in her own bedroom. Another resident was seen walking with her hand down her shirt, exposing her upper chest, without staff present to assist. Staff were also observed placing a clothing protector on a resident at the dining table without asking or speaking to her, and another resident was pulled away from an activity and taken to bed without being consulted or spoken to about her preferences. Additionally, there were incidents where residents' interactions during meals were not managed in a way that preserved dignity. One resident began grabbing food from another's tray, prompting the second resident to leave the table in frustration. Interviews with staff confirmed that residents were expected to be fully clothed in public areas and that staff were supposed to ask permission before providing care or moving residents. The facility's own behavioral health policy emphasized individualized approaches to care and promoting emotional and psychosocial well-being, which was not reflected in the observed practices.
Failure to Ensure Appropriate Use and Documentation for Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that several residents were free from unnecessary antipsychotic medication use without appropriate clinical indications or documented gradual dose reductions (GDRs). Specifically, four residents were administered antipsychotic medications for diagnoses such as dementia and psychosis, but the medical records lacked evidence of appropriate indications for use, physician-documented risk versus benefit statements, or recent attempts at GDRs. In several cases, the care plans directed staff to consult with pharmacy and physicians regarding dose reductions and to educate residents and families about the risks and benefits of these medications, but there was no documentation that these steps were consistently followed. For one resident with diagnoses including psychosis, Alzheimer's disease, and dementia with agitation, the electronic medical record showed ongoing antipsychotic medication orders with no recent GDR attempts or consultant pharmacist recommendations for continued use. Another resident with severe cognitive impairment and multiple behavioral symptoms was receiving two antipsychotic medications, but the consultant pharmacist's review did not include recommendations for appropriate indications. A third resident, newly admitted with dementia and other comorbidities, was prescribed an antipsychotic for dementia without an approved indication, and the consultant pharmacist had not yet reviewed the case. A fourth resident with multiple diagnoses, including dementia and psychosis, was on a high dose of antipsychotic medication, but the record lacked a physician-documented rationale for the risks versus benefits of continued use. Interviews with nursing staff and administration revealed uncertainty about appropriate indications for antipsychotic use, with staff acknowledging that dementia alone should not be used as a justification. The facility's own policy required that only necessary medications be used, with documentation of adequate indicators for use and regular evaluation of ongoing need, but these requirements were not met in the reviewed cases. Observations of the residents confirmed their ongoing use of antipsychotic medications without the necessary supporting documentation or clinical justification.
Failure to Prevent Accidents and Ensure Safe Environment for Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for multiple residents with significant cognitive and physical impairments. One resident with dementia, a history of cervical vertebra fracture, and a high fall risk was repeatedly observed in a reclined Broda chair with her call light out of reach, despite her care plan specifying that the call light should always be within reach. Staff interviews confirmed that the resident was unable to reposition herself or access the call light independently, and that all residents on the unit were considered high fall risks. The facility's own policy required interventions to minimize fall risk, but these were not consistently implemented as observed during the survey. Another resident with severe cognitive impairment, bilateral lower extremity impairment, and total dependence on staff for transfers and mobility suffered two separate head lacerations during staff-assisted transfers. In both incidents, documentation was incomplete or lacking, with no root-cause analysis or clear description of how the injuries occurred. Staff interviews revealed improper use of mechanical lifts, lack of supervision, and failure to immediately report and document injuries. Witness statements indicated that staff left the resident unattended during transfers, and that the resident became agitated, leading to injury. The facility's fall management policy required assessment and care planning for fall risks, but these procedures were not adequately followed. A third resident with dementia, unsteadiness, and a history of falls was found on the floor with a head laceration after an unwitnessed fall. The resident's bed was found in a high position, and the bed control was accessible to the resident, despite staff stating that residents with dementia should not have access to bed controls due to fall risk. The facility lacked an assessment to determine if the resident was safe to operate the bed device. The care plan required staff to ensure the resident was not put to bed until fatigued and to keep the call light within reach, but these interventions were not consistently implemented. The facility's failure to follow its own policies and care plans placed residents at risk for preventable falls and injuries.
Failure to Provide Consistent Dementia Care and Person-Centered Interventions
Penalty
Summary
The facility failed to provide consistent and appropriate dementia-related care services to multiple residents diagnosed with dementia and related cognitive impairments. Several residents exhibited behaviors such as physical and verbal aggression, wandering, entering other residents' rooms, taking belongings, and combative actions during activities of daily living (ADLs). Despite these ongoing behaviors, care plans often lacked person-centered interventions and specific staff directions tailored to the residents' individual needs. Staff responses were generally limited to redirection and reapproaching, which were frequently ineffective, and there was a lack of documented individualized strategies to address the challenging behaviors. For example, one resident with a history of strokes and severe cognitive impairment repeatedly became verbally and physically aggressive during ADL assistance, resulting in incidents such as hitting, pinching, and biting staff, as well as sustaining skin tears. Staff attempted redirection with minimal effect, and interviews revealed uncertainty among staff regarding the availability of person-centered interventions in the care plan. Another resident with severe cognitive impairment and a history of dementia exhibited wandering, aggression, and inappropriate behaviors, including entering other residents' rooms, taking items, and physical altercations with peers. Staff were observed intervening only after incidents occurred, and the care plan did not provide detailed, individualized interventions for these behaviors. Additional residents with dementia and related diagnoses were observed engaging in behaviors such as grabbing food from others, entering peers' rooms, and taking belongings. Staff interviews confirmed that supervision and redirection were expected, but there was a lack of clear, person-centered guidance in care plans. The facility was unable to provide a policy related to dementia care when requested, and the observed and documented deficiencies placed residents at risk for decreased quality of life, isolation, and impaired dignity, as noted in the report.
Failure to Identify and Report Inappropriate Antipsychotic Use and Lack of Gradual Dose Reduction
Penalty
Summary
The facility failed to ensure that the consultant pharmacist (CP) identified and reported the use of antipsychotic medications without appropriate indications for two residents diagnosed with dementia. For one resident with diagnoses including psychosis, Alzheimer's disease, and dementia with agitation, the medical record showed multiple orders for Seroquel, an antipsychotic, with the indication listed as psychosis. However, there was no appropriate indication documented for the use of this medication in a resident with dementia, and the CP did not recommend a gradual dose reduction (GDR) or address the lack of indication in their monthly reviews. The care plan directed staff to consult with pharmacy and the physician regarding dosage reduction and to discuss ongoing need for the medication, but these steps were not documented as completed. Interviews with nursing staff revealed uncertainty about appropriate indications for antipsychotic use in dementia and the process for communicating pharmacy review findings to physicians. A second resident, with diagnoses including dementia, cognitive communication deficit, and psychosis, was also prescribed Seroquel for psychosis. The resident's care plan included instructions for staff to consult with pharmacy and the physician to consider dosage reduction quarterly and to review behaviors and interventions. Despite this, the CP's monthly medication reviews over a year did not include recommendations regarding the inappropriate indication for the antipsychotic medication. Nursing staff interviews indicated a lack of clarity about their roles in acting on pharmacy reviews and ensuring correct indications for psychotropic medications were communicated to the physician. Facility policies required the pharmacist to report any irregularities to the attending physician, the medical record, and the director of nursing, and for the physician to document review and actions taken. The policies also emphasized the need for adequate documentation of medication indications and the use of non-pharmacological interventions. Despite these policies, the facility did not ensure that the CP identified or reported the lack of appropriate indications for antipsychotic use or recommended GDRs, nor did the physician document risk versus benefit for continued use in one case. These failures resulted in the continued administration of antipsychotic medications without proper justification or review.
Failure to Document PCV20 Vaccine Consent or Declination
Penalty
Summary
The facility failed to obtain consent or declinations for the Pneumococcal Conjugate Vaccine (PCV20) for several residents, as identified through record reviews and staff interviews. Specifically, five residents' records were reviewed for immunization status, and it was found that documentation was lacking for the offering, administration, or declination of the PCV20 vaccine. In some cases, records showed administration or declination of the PPSV23 vaccine, but there was no evidence that the PCV20 vaccine was addressed, nor was there documentation of a historical administration or physician-documented contraindication for PCV20. Interviews with nursing staff revealed inconsistencies in the tracking and administration process for immunizations. Staff members indicated that immunization status was tracked on the Treatment Administration Record (TAR) and by the infection preventionist, but there was uncertainty among staff regarding whether the PCV20 vaccine had been offered to residents. The facility's policy required adherence to state rules and incorporation of physician orders for pneumococcal vaccines, but the lack of documentation for PCV20 offerings or declinations indicated a failure to follow these procedures.
Failure to Accommodate Resident Food Preferences Due to Unauthorized Removal of Dietary Items
Penalty
Summary
Nursing staff failed to accommodate a resident's food preferences by removing dietary items from her meal trays, despite physician orders and care plan directives. Specifically, staff took toast and breadsticks from the resident's trays on multiple occasions, citing concerns about her blood glucose levels. The resident, who had a history of diabetes, Alzheimer's disease, and multiple other medical conditions, was on a regular diet with double protein and diabetic condiments as ordered by her physician. The care plan instructed staff to provide the diet as ordered and monitor intake, but staff instead made independent decisions to remove food items without consulting the physician. Observations and interviews revealed that both CNAs and licensed nurses routinely removed bread or dessert from diabetic residents' trays based on blood sugar readings, rather than following the prescribed diet orders. The resident was observed attempting to retrieve bread that had been taken away and even took bread from another resident's tray. Facility policy and administrative staff confirmed that residents should receive the food served on their trays and that staff should not remove food items. This practice was inconsistent with the resident's rights and the facility's own policies.
Failure to Notify Physician of Resident Head Injury
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in condition following a head injury sustained during staff-assisted care. The resident, who had severe cognitive impairment, dementia, a recent femur fracture, and was dependent on staff for all activities of daily living, was found with a three-centimeter laceration on his forehead. Staff discovered the injury after finding the resident in bed with a blood-soaked Band-Aid, and the wound was determined to require sutures. There was no documentation of nursing assessment or progress notes at the time of the injury prior to its discovery by the evening nurse. Witness statements from CNAs involved in the resident's care indicated that the injury occurred during or after a Hoyer lift transfer. Both CNAs left the resident unattended in his room, and upon returning, one CNA found the resident partially out of bed and later noticed the head wound after the resident became agitated and struck the CNA. The CNAs reported the injury to each other, but there was uncertainty about whether the incident was reported to a nurse or if the resident was assessed immediately, especially since the unit nurse had left early that day. The facility's policy required immediate notification of the physician for accidents requiring intervention. However, the physician was not notified until the evening nurse discovered the injury hours later, resulting in a delay in medical evaluation and treatment. The lack of timely documentation and communication with the physician constituted a failure to follow established protocols for changes in resident condition.
Failure to Issue Required Medicare Non-Coverage Notice Upon Discharge
Penalty
Summary
The facility failed to issue the required Center for Medicare/Medicaid Services (CMS) Notification of Medicare Non-Coverage Form 10123 (NOMNC) to a resident whose Medicare Part A episode began on 03/28/25 and ended on 04/16/25. The resident, who had met therapy goals and was discharged home, did not have documentation in the clinical record of receiving the NOMNC for this Medicare Part A episode. Interviews with Social Services and Administrative Nursing staff revealed that the facility did not provide NOMNC notices to residents discharged home with Medicare A days remaining, based on their understanding of the requirements. The facility's policy indicated a process for denial or end of benefits to inform residents and families, but this was not followed in the case reviewed.
Failure to Develop Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for two residents, resulting in uncommunicated care needs. For one resident with diagnoses including dementia, depression, cognitive communication deficit, and lack of coordination, the care plan did not include specific directions regarding personal hygiene preferences, particularly shaving. Despite the resident expressing a preference to be shaved daily and not to grow a beard, staff only provided shaving on shower days, and there was no documentation of his preference in the care plan or Kardex. Staff interviews confirmed that personal hygiene preferences were not clearly communicated or accessible, and observations over several days showed the resident with unshaven facial hair. Another resident with dementia, congestive heart failure, abnormal lung findings, and hypoxia had a care plan that lacked direction for oxygen therapy and the use of a BiPAP machine at bedtime, despite physician orders for these interventions. The care plan only noted the presence of equipment supplied by hospice but did not specify how or when to use the oxygen or BiPAP. Observations showed the resident using oxygen, but the tubing was not stored properly when not in use. Staff interviews revealed uncertainty about the correct oxygen flow rate and confirmed that respiratory care needs were not included in the care plan. The facility's policy required timely, person-centered, comprehensive care plans developed and revised by an interdisciplinary team with input from the resident or their representative. However, both residents' care plans lacked essential individualized information, and staff were not consistently aware of or able to access the residents' specific care preferences and needs, as evidenced by direct observation, record review, and staff interviews.
Failure to Revise Care Plan for Resident-Centered Behavioral Interventions
Penalty
Summary
The facility failed to revise the care plan to include resident-centered functional abilities for a resident with a history of cerebrovascular accident (CVA), hemiplegia, hemiparesis, muscle weakness, and severely impaired cognition. The resident's care plan directed staff to reassure her and to leave and return later if she was resistive with activities of daily living (ADLs), but did not include other person-centered interventions despite ongoing behavioral issues. Multiple behavior and event notes documented that the resident was frequently verbally and physically aggressive toward staff during assistance with ADLs, transfers, and medication administration. Incidents included hitting, pinching, kicking, biting, and grabbing staff, as well as verbal refusals and threats. Staff attempts to redirect the resident were minimally effective, and the resident continued to display aggressive behaviors during care. There were also documented instances of the resident sustaining skin tears during these episodes. Interviews with staff revealed uncertainty about the availability of person-centered interventions in the care plan and a reliance on reapproaching the resident later. The facility's policy required timely, person-centered, comprehensive care plans that are reviewed and revised by an interdisciplinary team, with updates made when changes in the resident's condition occur. Despite ongoing behavioral challenges and injuries, the care plan was not revised to include additional person-centered interventions.
Failure to Provide Person-Centered Assistance with Personal Hygiene
Penalty
Summary
Staff failed to provide necessary assistance with personal hygiene for a resident diagnosed with dementia, depression, cognitive communication deficit, and lack of coordination. The resident's medical record and MDS assessments documented severely impaired cognition and a need for substantial to maximum assistance with personal hygiene and dressing. The care plan indicated the resident required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene, but did not include specific directions regarding the resident's personal preferences for hygiene care. Over several days, the resident was repeatedly observed in common areas with several days of facial hair growth, despite stating a preference to be shaved daily and not to grow a beard. Interviews with staff revealed that shaving was typically performed only on shower days, and staff were unaware of the resident's daily shaving preference or where such preferences would be documented. Nursing staff acknowledged that the resident's choice should be listed in the care plan, and administrative staff stated that resident preferences were collected at admission but could be limited by cognitive impairment. The facility's policy required respect for resident dignity and individual preferences.
Failure to Apply TED Hose as Ordered for Edema Management
Penalty
Summary
The facility failed to follow a physician's order to apply thrombo-embolic-deterrent (TED) hose to a resident's lower extremities each morning to manage edema. The resident, who had multiple diagnoses including pain, hypertension, insomnia, cognitive-communication deficit, history of falls, muscle weakness, hyperlipidemia, aphasia, COPD, and dementia, was documented as requiring substantial to maximal assistance with daily activities and was receiving diuretic therapy for edema. The care plan and physician's orders specified that TED hose should be applied every morning and removed at bedtime to support skin integrity and manage swelling. Despite these orders, observations on multiple mornings showed the resident without TED hose, wearing only nonskid socks. Interviews with nursing staff and administration revealed a lack of clarity regarding responsibility for ensuring the TED hose were applied as ordered. Staff acknowledged that it was a shared duty among nursing personnel, but the resident was repeatedly observed without the prescribed compression stockings during morning hours.
Failure to Consistently Apply Ordered Pressure-Reducing Devices
Penalty
Summary
Surveyors identified that the facility failed to ensure the consistent application of physician-ordered pressure-reducing devices, specifically heel protectors and suspension boots, for two residents with significant risk factors for pressure ulcer development. One resident, with diagnoses including dementia, diabetes mellitus, and muscle weakness, had orders for bilateral heel suspension boots to be worn at all times when in bed, as well as instructions to encourage non-weight bearing on the right heel. Despite these orders, observations revealed that the resident was found in bed with her heels directly on the mattress and the suspension boots not in use. Staff interviews confirmed that the boots were not always applied, with a CNA expressing concern about falls if the resident attempted to ambulate while wearing them. A licensed nurse was unsure of the specific devices in place without checking the care plan, and administrative staff stated it was the responsibility of all staff to ensure devices were used as ordered. Another resident, with a history of cellulitis, hip fracture, muscle weakness, Alzheimer's disease, and existing stage 2 pressure ulcers, also had physician orders for heel protectors to be worn at all times when in bed. Multiple observations documented that this resident was in bed without heel protectors, with heels resting directly on the mattress. Staff interviews indicated that both nurses and CNAs had access to care plans and the Kardex, which outlined the need for heel protectors, and that it was the responsibility of both roles to ensure the devices were applied as ordered. The facility's own policy on skin integrity and pressure ulcer prevention required care consistent with professional standards to prevent pressure ulcers and to ensure the use of pressure-reducing devices as ordered. Despite this, the failure to apply the ordered devices as observed and confirmed by staff interviews placed both residents at increased risk for the development or worsening of pressure ulcers.
Failure to Apply Prescribed Knee Braces for Dependent Resident
Penalty
Summary
A deficiency was identified when staff failed to apply prescribed knee braces to a resident with significant cognitive and physical impairments. The resident, who had diagnoses including dementia, diabetes, pain, and a history of falls, was dependent on staff for all activities of daily living and unable to communicate needs. The care plan specified that the resident was to wear knee extension braces daily for as long as tolerated, and there was no documentation of the resident refusing the braces. However, during multiple observations, the resident was seen in a Broda chair without the knee braces applied. Interviews with nursing staff and review of facility policy revealed that all nursing staff had access to the resident's care plan and were responsible for ensuring the application of special equipment such as braces. Staff confirmed that any refusal to use such equipment would be documented, but no such documentation existed for this resident. The facility's restorative nursing policy emphasized the importance of promoting residents' optimal function through proactive care planning and monitoring, yet the required intervention of applying knee braces was not carried out as directed.
Failure to Provide Timely Catheter Care and Prevent UTI
Penalty
Summary
Staff failed to provide appropriate treatment and services to prevent potential urinary tract infections for a resident with an indwelling catheter. The resident, who had diagnoses including dementia with agitation, urinary retention, and chronic kidney disease, required extensive assistance and had severely impaired cognition. The care plan directed staff to perform catheter care every shift, keep the catheter bag and tubing below the level of the bladder, and observe for pain, discomfort, and signs of infection. However, the care plan did not specify the frequency for emptying the catheter bag. Observations revealed that the resident's catheter bag and tubing were visibly full of urine on multiple occasions throughout the day, including during lunch and later in the afternoon. Staff did not empty the catheter bag until after the resident was transferred back to bed, despite the bag being full for an extended period. Interviews with staff confirmed that the catheter bag should be emptied at least every shift and as needed, and that allowing the bag and tubing to become overfilled could result in urine backing up into the bladder, causing pain or infection. The facility's policy required regular emptying of the catheter bag to maintain unobstructed urine flow and prevent infection. Despite this, the resident's catheter bag was not emptied as required, and the care plan lacked clear instructions on the frequency of emptying. This failure to follow established protocols and physician orders resulted in the resident being placed at risk for complications and infection.
Failure to Ensure Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with multiple diagnoses, including dementia, congestive heart failure, abnormal lung findings, and hypoxia. The resident's medical record lacked documentation of an active order for oxygen therapy and did not include dosing instructions for oxygen administration. Additionally, the care plan did not address the use of oxygen therapy or BiPAP, despite the presence of related physician orders and equipment provided by hospice. Observations revealed the resident using oxygen tubing at the dining table, and on another occasion, the tubing was left unbagged directly on the table. Interviews with staff confirmed that oxygen equipment should be stored in a sanitary manner, such as in a bag when not in use, and that a specific physician order with dosing instructions was required for oxygen administration. Staff also acknowledged that respiratory care, including the use of BiPAP, should be included in the resident's care plan. The facility's own policy required safe administration and storage of oxygen, which was not followed in this case.
Failure to Ensure Competent Staffing and Timely Injury Assessment
Penalty
Summary
The facility failed to ensure that staff possessed the necessary competencies and skills to safely provide direct care and nursing services, resulting in preventable injuries and delayed medical treatment for a resident. Certified Nurse's Aide (CNA) Q was involved in two separate incidents where the resident sustained head lacerations requiring sutures. In the first incident, the resident received a scalp laceration during a transfer from a wheelchair to a bed using a sit-to-stand lift, with no clear explanation or root-cause analysis documented. Witness statements were referenced but not provided, and the incident report lacked details on how the injury occurred. In the second incident, CNA Q turned the resident without additional staff assistance during incontinence care, resulting in the resident hitting his head on a wall outlet and sustaining a forehead laceration. The resident was found with a blood-saturated bandage, and there was no documentation of a nursing assessment at the time of injury. The physician was not notified until the next shift, and the facility could not provide evidence that the resident was assessed by a nurse immediately following the injury. Staff interviews confirmed that injuries were not reported or assessed as required by facility policy.
Failure to Monitor Medication Parameters and Complete Orders
Penalty
Summary
The facility failed to ensure that two residents received medications according to physician-ordered parameters and complete medication orders. For one resident with multiple diagnoses including dementia, psychosis, hypertension, and chronic obstructive pulmonary disease, the physician ordered metoprolol with specific parameters to hold the medication if the systolic blood pressure was below 110 or the pulse was below 60. However, review of the Medication Administration Record (MAR) for April and May showed that blood pressure and pulse were not obtained or recorded prior to administration of metoprolol on all documented occasions. Staff interviews confirmed that these vital signs should have been checked and documented before giving the medication, and that the medication should be held if readings were out of range. Additionally, the same resident had a physician's order for diclofenac gel to be applied topically to both knees, but the order did not specify the dosage amount to be applied. Staff acknowledged that the order was incomplete and should have included the dosage. Facility policies required proper monitoring, accurate documentation, and adherence to prescriber orders, but these were not followed in the cases identified, resulting in the administration of medications without appropriate monitoring or complete orders.
Failure to Coordinate Hospice Services in Resident Care Plans
Penalty
Summary
The facility failed to ensure a coordinated plan of care for two residents who were receiving hospice services. Both residents had severe cognitive impairments and multiple complex medical diagnoses, including dementia, chronic kidney disease, and end-stage conditions requiring total dependence on staff for activities of daily living. Their care plans indicated they were on hospice and included general comfort measures, but lacked specific directions for staff regarding collaboration with hospice providers, such as contact information, the services and equipment provided by hospice, and the frequency of hospice visits. Interviews with nursing staff and administrative personnel revealed that while hospice information was available in a binder at the nurse's station, this information was not integrated into the facility's care plans. Staff acknowledged that the care plans should match and include all services the residents received, but confirmed that the facility care plans did not contain the necessary details from the hospice plans of care. The facility's own hospice policy required that each resident's written plan of care include both the most recent hospice plan and a description of the services furnished by the facility to maintain the resident's well-being. Observations and record reviews confirmed that the lack of integration and coordination between the facility's care plans and the hospice providers' plans placed the residents at risk for inappropriate end-of-life care. The deficiency was identified through review of medical records, care plans, and interviews with staff, which consistently showed that the required coordination and documentation were not present in the facility's care planning process.
Resident Abuse Due to Staff Retaliation
Penalty
Summary
The facility failed to protect a cognitively impaired resident, identified as R1, from physical abuse by a staff member. On the morning of October 9, 2024, a Licensed Nurse (LN) overheard a Certified Nurse Aide (CNA) telling R1 that she could not have sugar due to her diabetes, which upset R1. The LN observed R1 hitting the CNA in the stomach, after which the CNA retaliated by punching R1 in the left upper arm. This incident was immediately reported to the Administrative Nurse, who removed the CNA from the facility pending an investigation. R1's medical records indicated a diagnosis of dementia with severe cognitive impairment, generalized muscle weakness, and Parkinson's disease. The resident's care plan noted a potential for physical and verbal aggression due to dementia and poor impulse control, with specific interventions outlined for staff to follow when R1 became agitated. However, these interventions were not followed, leading to the escalation of the situation and resulting in physical abuse. The incident was witnessed by LN G, who provided a notarized statement confirming the sequence of events. The facility's investigation corroborated the LN's account, noting that R1 had a bruise on her left upper arm and complained of pain following the incident. The facility's policy on abuse emphasized the right of residents to be free from abuse and highlighted the increased risk when residents exhibit behaviors that may provoke staff reactions. Despite these guidelines, the staff's failure to adhere to the care plan and manage R1's behavior appropriately resulted in the abuse.
Removal Plan
- The facility suspended CNA M immediately pending investigation.
- The facility completed a skin assessment on R1 which revealed a bruise on R1's left upper arm.
- The facility notified the State Agency (SA) and law enforcement. Law enforcement obtained witness statements at the facility and provided a case number.
- The provider saw R1 following the incident.
- The facility completed an x-ray on R1's left arm/shoulder with no positive findings.
- The facility completed skin assessments on all residents on that unit.
- The facility interviewed all residents on that unit with a BIMS of 10 or higher for safety and abuse.
- Staff received abuse education.
- Social Services visited with R1 daily for three days.
- The facility terminated CNA M and banned her from returning.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent a cognitively impaired resident, who had a history of making comments about leaving and was at risk for falls, from eloping. On the day of the incident, the resident expressed a desire to go home to a housekeeping staff member, who then informed a licensed nurse. The nurse, however, did not immediately act on this information and was delayed by other tasks, during which time the resident left the facility unnoticed. The resident was found outside in the parking lot, sitting on the grass between two parked cars, in high temperatures. The door alarm for the stairwell, which the resident used to exit, did not sound because it had been turned off for unknown reasons. This lack of alarm allowed the resident to leave the building without staff being alerted, placing the resident in immediate jeopardy. The resident had a history of anxiety disorder, chronic respiratory failure, chronic kidney disease, and was dependent on supplemental oxygen. Despite these conditions and previous behaviors indicating a desire to leave, the resident's elopement risk was not adequately assessed or addressed in the care plan, contributing to the incident.
Removal Plan
- The facility placed R1 on one-on-one supervision.
- The facility updated R1's Care Plan to include the resident's risk for elopement.
- An Ad-Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held.
- Maintenance audited exit doors and alarms with continued audits planned.
- A key-access-only box was placed over the keypad for the second-floor stairwell door.
- Staff education on elopement was completed.
- An elopement drill was completed.
- Residents with a BIMS of 12 or below were audited.
- Residents at risk for elopement were audited with their care plans updated accordingly.
Failure to Provide Appropriate Dementia Care and Services
Penalty
Summary
The facility failed to provide appropriate dementia care and services for Resident 1 (R1), who was diagnosed with severe cognitive impairment, Parkinson's disease, and other related conditions. R1 exhibited behaviors such as physical aggression, rejection of care, and wandering. Despite having a care plan that included specific interventions to manage these behaviors, staff did not consistently follow these interventions. For instance, R1's care plan included preferences for music, television shows, and activities that could help in redirection, but these were not effectively utilized by the staff during incidents of agitation and aggression. On one occasion, Activity AA was observed smacking R1's hands and using inappropriate language when R1 attempted to grab coloring supplies. This incident was witnessed by Consultant GG, who intervened and reported the behavior. Activity AA's actions were not in line with the resident-specific interventions outlined in R1's care plan, which emphasized gentle redirection and engagement in meaningful activities. Additionally, staff members, including CNAs and activity personnel, had varying levels of awareness and access to R1's care plan, leading to inconsistent application of the prescribed interventions. Interviews with staff revealed that while some were aware of R1's care plan and the need for specific interventions, others were not. For example, CNA M stated that she did not have access to care plans and described general strategies for redirecting R1 that were not always aligned with the care plan. This lack of consistent knowledge and application of R1's care plan contributed to the deficient practice, affecting R1's ability to maintain her highest practicable level of physical, mental, and psychosocial well-being.
Failure to Ensure Proper ADL Assistance and Weight-Bearing Restrictions
Penalty
Summary
The facility failed to ensure that a resident (R1) received the necessary assistive care and services with activities of daily living (ADL) to maintain her highest practicable ability and promote independence. R1 had a complex medical history, including multiple fractures, dementia, and a history of falls. Despite these conditions, the facility did not provide adequate care instructions or follow through on weight-bearing restrictions, leading to inconsistent and potentially harmful care practices. For instance, R1's care plan lacked specific directions for ADL assistance and weight-bearing restrictions, and there were discrepancies in the staff's understanding and implementation of these restrictions. R1's medical records and staff interviews revealed that there were significant lapses in communication and documentation regarding her weight-bearing status. Although R1 was initially non-weight bearing on her lower extremities, staff were not consistently informed or aware of these restrictions. This led to instances where R1 was improperly assisted to walk, causing her pain and potentially risking further injury. For example, on one occasion, a Certified Nurse Aide (CNA) walked R1 to the bathroom despite her weight-bearing restrictions, resulting in R1 experiencing pain. The facility's policy on ADLs required that residents receive appropriate treatment and services to maintain and improve their ability to carry out daily activities. However, the facility did not adhere to this policy, as evidenced by the lack of clear care instructions and the failure to ensure staff were aware of and followed R1's weight-bearing restrictions. This deficiency placed R1 at risk for injury, pain, and decreased ability to perform ADLs, highlighting a significant lapse in the facility's care practices and communication protocols.
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Illustrative
What surveyors actually found near you
We read the 861 citations issued within 25 miles in the last 12 months — including the 21 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Overland Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shawnee Post Acute Rehabilitation Center | 1.1 mi | ★★★★★ | 12 | 0 |
| Shawnee Gardens Healthcare & Rehab Center | 1.5 mi | ★★★★★ | 2 | 0 |
| Westchester Village Of Lenexa | 2.1 mi | ★★★★★ | 0 | 0 |
| Merriam Gardens Healthcare & Rehabilitation Center | 2.3 mi | ★★★★★ | 0 | 0 |
| Aspen Health And Wellness | 2.4 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.