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 Swan Health At Overland Park during CMS and state inspections, most recent first.
A resident with complex medical needs and dependent on enteral nutrition experienced ongoing and significant weight loss, with no documented interventions or increased monitoring by staff until the loss became severe. Despite facility policy requiring prompt response to weight changes, staff failed to adjust feeding regimens or increase the frequency of weight checks in a timely manner, and no dietary assessments were completed during the period of decline.
The facility did not ensure consistent RN coverage for eight consecutive hours each day as required, with staffing records and schedules showing multiple days without documented RN presence. Administrative staff reported covering some shifts, but these hours were not accurately reflected in the official documentation, and timecard data for the missing days could not be retrieved due to a system change.
The facility did not conduct a comprehensive assessment to determine specific staffing needs for day, night, and weekend shifts, instead only documenting total daily staffing requirements. Payroll data showed consistently low weekend staffing, and administrative staff confirmed the assessment lacked shift-specific details, affecting all residents.
The facility failed to submit accurate PBJ staffing data to CMS, particularly for weekend coverage, despite internal records and staff interviews indicating adequate staffing and administrative nurse coverage for call-offs. The facility's assessment did not specify required nursing hours for different shifts, contributing to the inaccurate reporting.
The facility did not implement an effective antibiotic stewardship program or track antibiotic use, resulting in a lack of identification and monitoring of possible infection outbreaks. The Infection Preventionist confirmed that antibiotic use was not tracked, and the infection control log did not identify facility-acquired infections.
Three medication carts containing resident and stock medications, as well as medicated ointments, were observed unlocked and unsupervised in a hallway. Nursing staff confirmed the carts should have been locked when not in use, but failed to do so, contrary to facility policy requiring all medications to be secured.
Two residents received unnecessary psychotropic medications, including antipsychotics prescribed for non-approved indications such as depression and insomnia, and PRN orders without required stop dates or proper clinical justification. Nursing and administrative staff acknowledged these practices were inconsistent with facility policy and regulatory requirements, resulting in the risk of chemical restraint.
Two residents did not have required Care Area Assessment (CAA) analyses completed after their admission MDS triggered multiple care areas, including functional abilities, urinary incontinence, pressure ulcers, psychotropic drug use, falls, and nutritional status. Administrative nursing staff were unable to explain the missing analyses, despite facility policy assigning this responsibility to an RN.
A resident with multiple medical conditions, including depression and quadriplegia, was prescribed Seroquel, an antipsychotic, for depression. The Consultant Pharmacist identified that Seroquel could not be used for depression but did not address that depression is not a CMS-approved indication for antipsychotic use. Nursing and administrative staff confirmed antipsychotics should not be used for depression, and facility policy required the pharmacist to review and report such irregularities. Despite this, the medication continued to be administered for an unapproved indication.
Two residents did not receive care in accordance with physician orders regarding medication administration and monitoring. One resident with diabetes and heart failure had multiple blood glucose readings outside the ordered parameters without physician notification or documentation. Another resident with hypertension received antihypertensive medication outside the prescribed blood pressure parameters on several occasions, also without required documentation. Staff interviews confirmed expectations for following orders and documenting deviations, but these were not met.
Dietary staff did not follow approved recipes when preparing pureed meals for a resident, instead using water as an additive and inconsistently adding thickener. Staff admitted to not following recipes, and the facility could not provide a policy for altered diet preparation.
Surveyors found that the facility did not update its daily posted nurse staffing information, with documentation remaining unchanged for several days. Staff confirmed that the posting should be updated daily by nursing administrators, but this was not done when the responsible administrator was absent, resulting in outdated staffing information being displayed.
A resident in a persistent vegetative state with a PEG tube experienced neglect when the facility failed to provide adequate monitoring and timely care for her feeding tube site, leading to an infection. Despite signs of infection and displacement, staff delayed appropriate intervention, resulting in the resident's condition worsening. The resident was eventually transferred to the hospital, where it was discovered that the PEG tube was outside of the stomach, and she had a severe abdominal wall infection. The resident passed away the same day, and the facility's actions were deemed neglectful, placing the resident in immediate jeopardy.
A facility failed to protect residents' trust funds from misappropriation by an administrative staff member responsible for managing these accounts. The investigation revealed unauthorized withdrawals and checks written from the resident trust account without proper documentation or authorization. This lack of oversight placed all residents with trust accounts at risk for financial instability and impaired rights.
A resident with a PEG tube and anoxic brain damage developed cellulitis around the tube site, requiring antibiotic treatment. The facility failed to notify the resident's representative of this new medication order, leading to a risk of miscommunication. Staff interviews indicated an expectation to notify representatives of changes, but the facility's policy did not address this requirement.
The facility failed to report suspected misappropriation of resident funds to the State Agency and law enforcement within the required timeframe. An investigation revealed discrepancies involving large checks written to an administrative staff member and unauthorized withdrawals from resident accounts. Despite identifying these issues, the facility delayed reporting, placing residents with trust accounts at risk.
Failure to Implement Timely Interventions for Significant Weight Loss in Enteral-Fed Resident
Penalty
Summary
The facility failed to implement timely and appropriate interventions to address ongoing and significant weight loss in a resident who was dependent on enteral nutrition via PEG tube. The resident, who had a complex medical history including nontraumatic subarachnoid hemorrhage, conversion disorder, dysphagia, cerebral edema, and ventilator dependence, experienced a weight loss of 3.85% within the first month of admission, which progressed to a significant loss of 8.85% by the second month. Despite these documented losses, there was no evidence in the medical record of any interventions or responses from the facility until over two months after admission, when the weight loss had reached 11.15%. The resident's care plan and physician orders directed monthly weights and specified enteral feeding regimens, but there was no documented adjustment to the feeding orders or increased monitoring in response to the early weight loss. The resident's electronic medical record lacked evidence of dietary assessments or progress notes addressing the weight loss between admission and the point when the loss became significant. Staff interviews revealed that weights were typically obtained monthly, and that the dietitian was responsible for monitoring and making dietary adjustments. However, both the dietitian and administrative staff acknowledged that interventions, such as increasing the frequency of weight monitoring and adjusting feeding methods, should have been implemented sooner when the initial weight loss was observed. The dietitian also noted that no dietary assessments were completed in July when the first weight loss was documented, and that the resident remained on monthly weights despite ongoing decline. Facility policy required staff to report significant weight changes and for the dietitian to monitor and recommend interventions for residents receiving enteral nutrition. Despite this, the resident's weight loss was not addressed in a timely manner, and there was a lack of documentation of any interventions or increased monitoring until the weight loss became severe. Staff interviews confirmed that the process for monitoring and responding to weight loss was not followed as required, contributing to the continued decline in the resident's nutritional status.
Failure to Maintain Consistent RN Coverage
Penalty
Summary
The facility failed to provide consistent Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week, as required. A review of the facility's Payroll Based Journaling (PBJ) Staffing Data Report revealed that there was no RN coverage on twelve occasions, and for eight of those days, there were no accounted RN hours according to the facility's working schedules and daily posted staffing. The facility was unable to provide documentation for the missing RN coverage on these days when requested. Administrative staff stated that they sometimes covered shifts, but the hours may not have been accurately reflected in the PBJ documentation, and the administrator was unable to retrieve timecard data for the missing days due to a system changeover. The facility's own policy required an RN to be on duty at least eight consecutive hours every 24 hours, seven days a week.
Failure to Conduct Comprehensive Facility-Wide Resource Assessment
Penalty
Summary
The facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during both day-to-day operations and emergencies. The assessment provided by administrative staff was updated annually and identified required staffing needs per day, but did not specify staffing needs for day, night, and weekend shifts. Review of the facility's Payroll Based Journaling (PBJ) data revealed excessively low weekend staffing in all four quarters reviewed. Additionally, administrative staff confirmed that the assessment did not separate required hours by shift, only showing total required hours. The facility's policy required a documented assessment to determine necessary resources for resident care during daily operations, but this was not fully implemented.
Inaccurate PBJ Staffing Data Submission for Weekend Coverage
Penalty
Summary
The facility failed to submit accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) through Payroll Based Journaling (PBJ), specifically regarding weekend staffing coverage hours. A review of the facility's PBJ data for multiple fiscal quarters showed that the facility triggered for excessively low weekend staffing. However, examination of the facility's working schedules, time sheets, and posted staffing hours did not reveal any gaps or loss of hours, and weekend call-offs were documented as being covered by administrative nurses. Further review of the facility's updated Facility Assessment indicated that it did not differentiate required nursing hours for day, evening, and weekend shifts. Interviews with nursing staff and administrative nurses confirmed that the facility was typically well-staffed on weekends, with administrative nurses covering any call-offs. Despite this, the PBJ data submitted to CMS did not accurately reflect the actual staffing coverage, resulting in a deficiency for failing to report complete and accurate staffing information as required by facility policy.
Failure to Implement Antibiotic Stewardship and Infection Tracking
Penalty
Summary
The facility failed to develop and implement the core elements of an antibiotic stewardship program as part of its infection prevention and control efforts. Review of the Infection Control Log from May 2024 through April 2025 showed no evidence of tracking or identifying possible infection outbreaks, and the log did not identify facility-acquired infections. During an interview, the facility's Infection Preventionist confirmed that antibiotic use was not being tracked to monitor for potential infection outbreaks. The facility's Infection Prevention Plan policy outlined the need for surveillance and reporting of infectious agents, but these practices were not followed as required.
Unsecured Medication Carts Found Unattended
Penalty
Summary
Three medication carts were found unlocked and unsupervised on the facility's 200 hallway during an inspection, with resident medications, stock medications, and medicated ointments stored inside. Licensed nurses acknowledged that the carts should have been locked when not in use or supervised, but had left them unsecured for a period of time. The facility's policy required all medications and biologicals to be locked and secured to prevent tampering or exposure, but this protocol was not followed during the observed incident.
Failure to Prevent Unnecessary Psychotropic Medication and Chemical Restraint
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications and chemical restraints for two residents. One resident with quadriplegia, severe cognitive impairment, and total dependence on staff was administered Seroquel, an antipsychotic, for depression, despite the absence of a psychiatric or mood disorder diagnosis and no CMS-approved indication for antipsychotic use in depression. The resident also received PRN Lorazepam for anxiety with an indefinite order lacking a required stop date. The consultant pharmacist identified these issues, noting the inappropriate use of Seroquel for depression and the need for a defined duration for Lorazepam, but the orders were not appropriately updated or discontinued as required. Another resident with paraplegia and intact cognition received antipsychotic medications, including Diazepam and Seroquel, for muscle spasms and insomnia, respectively. The Diazepam orders were PRN without a 14-day stop date or specific duration, and Seroquel was prescribed for insomnia, which is not an approved indication for antipsychotic use. The consultant pharmacist recommended clinical rationale and duration for Diazepam and questioned the indication for Seroquel, but the facility was unable to provide appropriate physician documentation for the use of antipsychotics with non-approved indications. Interviews with nursing staff and administrative nurses confirmed that antipsychotic medications should not be used for depression or insomnia and that PRN psychotropic medications require a 14-day stop date and physician evaluation for continued use. The facility's own policy also required these safeguards, but they were not followed. These actions and inactions resulted in the administration of unnecessary psychotropic medications and the risk of chemical restraint for the affected residents.
Failure to Complete CAA Analyses for Two Residents
Penalty
Summary
The facility failed to complete the Care Area Assessment (CAA) analysis of findings for two residents following their admission, as required by the Comprehensive Minimum Data Set (MDS) process. For one resident, the Admission MDS triggered CAAs for functional abilities, urinary incontinence and indwelling catheter, pressure ulcer, and nutritional status, but none of these CAAs included a completed analysis of findings. For another resident, the Admission MDS triggered CAAs for functional abilities, urinary incontinence and indwelling catheter, pressure ulcer, psychotropic drug use, falls, and nutritional status, with all triggered CAAs also lacking the required analysis. Interviews with administrative nursing staff revealed they were unable to provide information regarding the missing analyses. The facility's policy states that a registered nurse is responsible for conducting and coordinating the completion of the resident assessment.
Failure to Ensure CMS-Approved Indication for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) recommended a Centers for Medicare and Medicaid Services (CMS) approved indication for an antipsychotic medication prescribed to a resident. The resident had a history of depression, quadriplegia, muscle weakness, dysphagia, and COPD, and was completely dependent on staff for all activities of daily living. The resident's medical record included an order for Seroquel, an antipsychotic, to be administered via gastrostomy tube at bedtime for depression. The CP's medication regimen review noted that Seroquel could not be used for depression, but did not acknowledge that depression is not an accepted CMS indication for antipsychotic use. The medical provider noted a failed gradual dose reduction, but the documentation did not address the lack of an appropriate indication for the medication. Interviews with nursing staff and administrative nurses confirmed that antipsychotic medications should not be used for depression and are intended for mental disorders such as behavioral and mood disorders. The facility's policy required the CP to complete monthly medication reviews and report irregular findings, including making recommendations based on medication indications. Despite these requirements, the CP did not ensure that the antipsychotic was prescribed for a CMS-approved indication, resulting in the continued administration of the medication for an unapproved use.
Failure to Follow Physician Orders for Medication Administration and Monitoring
Penalty
Summary
The facility failed to ensure that physician orders regarding medication administration and monitoring were followed for two residents. For one resident with diagnoses of congestive heart failure and diabetes mellitus, the physician had ordered blood glucose monitoring four times daily, with instructions to notify the physician if blood sugar levels were less than 30 or greater than 350. Over a 94-day period, this resident's blood sugar was outside the ordered parameters on twelve occasions, but there was no documentation that the physician was notified as required. Both nursing staff and administrative staff confirmed that physician notification and documentation were expected when blood sugars were outside the specified range. The facility was unable to provide a policy related to following physician orders. For another resident with chronic respiratory failure, hypoxia, hypertension, and muscular dystrophy, the physician ordered Metoprolol to be administered twice daily for hypertension, with instructions to hold the medication if systolic blood pressure was less than 110 mmHg. Review of the medication administration record showed that Metoprolol was given outside the ordered parameters on ten occasions, with no documentation explaining why the medication was administered despite the blood pressure being below the threshold. Nursing and administrative staff confirmed that medication parameters should be followed and that any deviations should be documented, including the reason for administering medication outside of parameters if instructed by the physician. The facility's medication monitoring policy indicated that medications should be given per physician orders and that irregular medication findings should be reported and corrected. However, the observed practices for these two residents did not align with the policy or physician instructions, as required notifications and documentation were not completed.
Failure to Follow Approved Recipes for Pureed Diets
Penalty
Summary
Dietary staff failed to follow nutritionally approved recipes during the preparation of pureed meals for a resident on a puree textured diet. Observations showed that staff used water as an additive in the food processor when pureeing cooked parmesan chicken, spaghetti with marinara sauce, and peas, and also added thickener inconsistently, rather than following the prescribed recipes. When questioned, the dietary staff member admitted to not following the recipes, citing experience as the reason. Another dietary staff member confirmed that water should not be used as an additive and that recipes should be followed for altered diets. The facility was unable to provide a policy related to altered diet preparation.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to update its daily posted nurse staffing information as required. During inspections on multiple days, surveyors observed that the staffing documentation posted in the cafeteria area was dated several days prior and had not been updated daily. Staff interviews confirmed that the form should be updated each day by nursing administrators, but this had not occurred since the administrator responsible had been off work. The facility's policy requires daily posting and maintenance of staffing records, but this procedure was not followed, resulting in inaccurate and outdated staffing information being displayed.
Neglect of Resident with PEG Tube Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to prevent the neglect of a resident, identified as R1, who was dependent on staff for her activities of daily living due to her persistent vegetative state and required a feeding tube for nutrition. The deficiency arose when staff did not provide adequate monitoring and timely care for R1's percutaneous endoscopic gastrostomy (PEG) tube site, which led to an infection. The infection caused R1's abdomen to become swollen and inflamed, with darkening and bruising noted on her right lower abdomen. Despite the presence of these symptoms, the facility's staff did not take immediate and appropriate action to address the complications. R1's medical records indicated that she had a history of anoxic brain damage and was in a persistent vegetative state, requiring tube feeding for more than half of her daily caloric intake. The facility's care plan for R1 included directives for staff to monitor and report any signs of infection or complications related to the PEG tube. However, the staff failed to adhere to these directives, as evidenced by the lack of timely intervention when R1's PEG tube site showed signs of infection and displacement. The staff's inaction resulted in R1 developing cellulitis around the PEG tube site, which was not promptly addressed, leading to further complications. The situation escalated when R1's condition deteriorated, with her abdomen becoming distended and tender, and the PEG tube balloon appearing displaced. Despite these alarming signs, there was a delay in sending R1 to the hospital for further evaluation. When R1 was finally transferred to the hospital, it was discovered that the PEG tube was outside of the stomach, and she had a severe abdominal wall infection. Unfortunately, R1 passed away the same day at the hospital. The facility's failure to provide necessary monitoring and treatment for R1's PEG tube complications constituted neglect and placed R1 in immediate jeopardy.
Removal Plan
- The facility educated all LN in an in-service provided by Administrative Nurse D on PEG tubes, notification of changes, and abuse/neglect/exploitation.
- Administrative Nurse D rounded on all 23 residents with PEG tubes to ensure proper placement.
- Administrative Nurse D or designee rounded daily using the PEG Tube Nursing Audit Tool.
- Administrative Nurse D reviewed the information from the audits and reported findings to the Quality Committee.
Misappropriation of Resident Trust Funds by Administrative Staff
Penalty
Summary
The facility failed to protect residents' trust funds from misappropriation by Administrative Staff B, who was responsible for managing these accounts. The investigation revealed that several large checks were written from the resident trust account to Administrative Staff B, with withdrawals not matching the written checks. Additionally, there were multiple transactions from residents' accounts that lacked proper documentation, such as signed withdrawal receipts and records, indicating a lack of oversight and control over the funds. The investigation into the misappropriation began when credit card fraud was discovered on the company credit card, attributed to Administrative Staff B. This led to a deeper audit of the Resident Funds Management Systems (RFMS), uncovering unauthorized withdrawals from the accounts of three residents. The facility identified that checks were written from the RFMS account without being linked to specific residents, and withdrawals were made without the necessary receipts or signatures from the residents or Administrative Staff B. The facility's policies required that no funds be disbursed without appropriate written authorization from the resident or their legal representative. However, the lack of adherence to these policies allowed for the misappropriation to occur, placing all residents with trust accounts at risk. The facility's failure to ensure proper management and documentation of resident funds resulted in financial instability and impaired rights for the affected residents.
Failure to Notify Resident's Representative of Care Plan Changes
Penalty
Summary
The facility failed to notify Resident 1's representative of changes in the plan of care, specifically regarding a new medication order for cellulitis around the PEG tube site. Resident 1, who had a history of anoxic brain damage and required tube feeding due to dysphagia, developed a swollen abdomen with a palpable mass and signs of infection at the PEG tube site. Despite the initiation of an antibiotic treatment (Augmentin) for cellulitis, there was no documented evidence that the resident's representative was informed of this new order. Interviews with nursing staff revealed that they were expected to notify the resident's representative of any new orders or changes in condition, and to document these notifications in the electronic medical record (EMR). However, the facility's policy on physician notification of change in condition did not address the requirement for notifying the resident's representative. This oversight led to a risk of miscommunication between the resident, their representative, and the facility.
Failure to Timely Report Misappropriation of Resident Funds
Penalty
Summary
The facility failed to report the suspicion of misappropriation of resident funds to the State Agency (SA) and law enforcement within the required timeframe. The issue was identified when the facility initiated an investigation on 12/11/24 after discovering credit card fraud on the company credit card linked to Administrative Staff B. During the investigation, several large checks from the resident funds account were found to be written to Administrative Staff B, with withdrawals not matching the written checks. Further discrepancies were identified on 12/17/24, including withdrawals from the accounts of three residents without receipts signed by them and checks written from the RFMS account not linked to any specific resident. Despite these findings, the facility delayed reporting the incident to the SA until 01/16/25 and to law enforcement until 01/22/25. The facility's policy, last revised in February 2020, required immediate reporting of any suspected or actual abuse, neglect, or exploitation to the SA and law enforcement. The delay in reporting placed all residents with trust accounts managed by the facility at risk for unidentified and ongoing misappropriation. The facility's actions, including the suspension and eventual resignation of Administrative Staff B, did not mitigate the failure to report the incident in a timely manner, as required by their policy.
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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.
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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) |
|---|---|---|---|---|
| Overland Park Post Acute | 0.8 mi | ★★★★★ | 5 | 0 |
| Advanced Health Care Of Overland Park | 1.1 mi | ★★★★★ | 2 | 0 |
| Brookdale Overland Park | 2.1 mi | ★★★★★ | 11 | 0 |
| Village Shalom Inc | 2.5 mi | ★★★★★ | 0 | 0 |
| Ignite Medical Resort Carondelet Llc | 3.2 mi | ★★★★★ | 34 | 0 |
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