Brookdale Overland Park

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure Resident (R) 1 was treated with dignity and respect when Certified Nurses Aide (CNA) M snapped her fingers at R1 in order to get his attention so he would stop acting out.

Inspectors wroteThe facility had a census of 77 residents. The sample included 18 residents, with two reviewed for accidents. Based on observation, record review, and interview, the facility failed to secure a blanket warming equipment and pressurized supplemental oxygen tanks in a safe, locked area and out of reach of the eight cognitively impaired, independently mobile residents. Findings Included:- On 01/19/26 at 07:04 AM, a walkthrough of the facility revealed an unsecured storage closet next to the nurse's station on the 400 hallway. An inspection of the unsecured closet revealed 25 (full size) and six (small) fully pressurized cylindrical oxygen containers in the oxygen racks. An inspection of the unsecured closet also revealed an Enthermics EC2060 blanket warming unit. The unit was warm to touch and set to 200 degrees Fahrenheit. [...]

Inspectors wroteThe facility identified a census of 77 residents. The sample included 18 residents, with six residents reviewed for unnecessary medication. Based on record review and interviews, the facility failed to ensure Resident (R) 70's as-needed Lorazepam, antianxiety (a class of medications that calm and relax people) medication had a 14-day stop date, or a physician's rationale for extended use.

Inspectors wroteThe facility identified a census of 77 residents. The sample included 18 residents, with one resident reviewed for hospice services. Based on interviews, observation, and record review, the facility failed to provide a description of the medication, services, and equipment provided to Resident (R) 51 by hospice.

Inspectors wroteThe facility identified a census of 78 residents. The sample included 23 residents. Based on record review, observations, and interviews, the facility failed to ensure adequate infection control standards were followed during Resident (R)189's enteral meal (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew, or swallow food) administration and storage of R290's oxygen therapy equipment. The facility additionally failed to ensure clean linen storage. This deficient practice placed the residents at risk for infectious diseases. Findings Included: - On 03/04/24 at 07:17 AM an inspection of the 400 Hall clean linen storage closet revealed a dusty, visibly soiled vacuum cleaner stored in the closet next to uncovered clean linen. [...]

Inspectors wroteThe facility identified a census of 78 residents. The sample included 23 residents with 10 reviewed for pneumococcal (type of bacterial infection) immunizations. Based on record review and interviews, the facility failed to ensure the resident and/or resident's representatives were informed and educated on the pneumococcal vaccination options and provided the current Vaccination Information Statements (VIS) for Residents (R) 30, R48, R50, R66, and R76. This deficient practice placed the residents at risk for complications related to infectious diseases. Findings Included: - On 03/06/24 at 08:00 AM a review of pneumococcal immunizations was completed for R13, R20, R30, R32, R33, R48, R50, R59, R66, and R76. R30's (severely cognitively impaired resident) Electronic Medical Record (EMR) indicated she was admitted to the facility on [DATE]. [...]

Inspectors wroteThe facility identified a census of 78 residents. The sample included 23 residents with five residents reviewed for activities of daily living (ADLs). Based on observations, record review, and interviews, the facility failed to promote care for Resident (R) 30, who was dependent on staff assistance for all ADLs, in a manner that preserved R30's dignity. These deficient practices placed the resident at risk for impaired psychosocial well-being and an undignified living environment.

Inspectors wroteThe facility identified a census of 78 residents. The sample included 23 residents. Based on observation, record review, and interviews, the facility failed to identify a significant change in the physical condition and complete a comprehensive Significant Change Minimum Data Set (MDS) for Resident (R) 33 with the addition of hospice services. This deficient practice placed R33 at risk for unidentified care needs.

Inspectors wroteThe facility identified a census of 78 residents. The sample included 23 residents. Based on observations, record reviews, and interviews, the facility failed to ensure accurate assessment and documentation on the Minimum Data Set (MDS) related to Resident (R)87's discharge location. This deficient practice had the risk of miscommunication related to R87's continued care needs. Findings Included: - The Medical Diagnosis section within R87's Electronic Medical Records (EMR) included diagnoses of atrial fibrillation (A-fib: rapid, irregular heartbeat), hypertension (high blood pressure), muscle weakness, history of sepsis (a life-threatening systemic reaction that develops due to infections which cause inflammation throughout the entire body), syncope (fainting or passing out), and repeated falls. [...]

Inspectors wroteThe facility identified a census of 78 residents. The sample included 23 residents with five residents reviewed for activities of daily living (ADLs). Based on observations, record review, and interviews, the facility failed to provide ADL assistance to Resident (R) 30, who was dependent on staff assistance for all ADLs. These deficient practices placed the residents at risk of decreased psycho-social well-being and impaired ADL.

Inspectors wroteThe facility identified a census of 78 residents. The sample included 23 residents with four residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure two residents, Resident (R) 13 and R28 received pressure-reducing interventions for pressure ulcers. This placed R13 and R28 at increased risk for pressure ulcer development.

Inspectors wroteThe facility identified a census of 78 residents. The sample included 23 residents with three reviewed for bowel and bladder management. Based on observations, record review, and interviews, the facility failed to ensure appropriate Foley catheter care (a tube inserted into the bladder to drain urine into a collection bag) for Resident (R)340 when staff failed to maintain the urine collection bag below R340's bladder to encourage dependent drainage. This deficient practice placed R340 at risk for complications related to urinary tract infections (UTI). Findings Included: [...]

Inspectors wroteThe facility identified a census of 78 residents. The sample included 23 residents with one resident sampled for intravenous (IV-administered directly into the bloodstream via a vein) therapy. Based on observation, record review, and interview, the facility failed to assess and document the location, appearance, and patency (the quality of being open and unobstructed) each shift for Resident (R) 191's IV access site. This placed R191 at risk of infection and complications related to IV therapy.

Inspectors wroteThe facility identified a census of 78 residents. The sample included 23 residents with seven residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities regarding the lack of dosing instructions for Voltaren (topical pain reliever medication) gel for Resident (R) 33. This deficient practice had the risk of unnecessary medication use and physical complications for R33.

Inspectors wroteThe facility identified a census of 78 residents. The sample included 23 residents with five residents sampled for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure a dosage was indicated for the use of Voltaren (a topical gel used for the treatment of pain) for Resident (R) 73 and R33. This deficient practice placed R73 and R33 at risk for unnecessary medication administration and possible adverse side effects.

Inspectors wroteThe facility identified a census of 78 residents. The sample included 23 residents. Based on observation, record review, and interviews, the facility failed to ensure that physician-ordered laboratory test results for Resident (R) 28 were included in R28's clinical record. This deficient practice could result in unnecessary tests and delayed treatment.

Inspectors wroteThe facility identified a census of 78 residents. The sample included 23 residents with two residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure a communication process was implemented, which included how the communication would be documented between the facility and the hospice provider, and a failed to provide a description of the services, medication, and equipment provided to Resident (R) 33 by hospice. This deficient practice created a risk for missed or delayed services and impaired physical, and psychosocial care for R33.

Inspectors wroteThe facility identified a census of 80 residents. The sample included 18 residents with seven reviewed for medication regimen review. Based of observations, record review, and interviews, the facility failed to ensure that the Consulting Pharmacist (CP) identified Resident (R)27's blood pressure medication given outside of physician ordered parameters. The CP also did not identify and report an inappropriate diagnoses for R11, R31, and R64's antipsychotic medications (class of medications used to treat psychosis and other mental emotional conditions). This placed the residents at risk for unnecessary medication and adverse side effects. Findings Included: [...]

Inspectors wroteThe facility identified a census of 80 residents. Based of observations, record review, and interviews, the facility failed to promote adequate infection control practices related to wound care for Residents (R)72, R33, R73, and R180. This deficient practice placed the residents at risk for complications related to wound infections and increased the risk for cross contamination. Findings Included: - On 09/07/22 at 10:20AM while performing wound care to R180, Licensed Nurse (LN) G gathered supplies and placed a Chux pad (absorbent disposable barrier) under R180. LN G washed her hands and donned gloves. LN G opened the supplies onto the Chux pad. LN G then removed the old bandages and threw them into the trash can. LN G then cleaned the wound area with the same soiled gloves. LN G removed her gloves and threw them in the trash. [...]

Inspectors wroteThe facility identified a census of 80 residents. The sample included 18 residents with three reviewed for activities of daily living (ADL's). Based on observations, record review, and interviews, the facility failed to provide R72's scheduled bathing per her preferred bathing schedule. This deficient practice placed R72 at risk for poor hygiene and related complications. Findings Included: [...]

Inspectors wroteThe facility identified a census of 80 residents. The sample included 16 residents with one resident reviewed for respiratory services. Based on observation, record review, and interviews, the facility failed to store oxygen tubing and nasal cannula (device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) in a sanitary manner for Resident (R) 131. This deficient practice placed R31 at increased risk to develop a respiratory infection.

Inspectors wroteThe facility identified a census of 80 residents. The sample included 18 residents with seven reviewed for unnecessary medications. Based of observations, record review, and interviews, the facility failed to ensure that the physician's ordered medication parameters were followed for Resident (R)27 and R39's blood pressure medication. This deficient practice placed the resident's at risk for unnecessary medication administration and adverse side effects. Findings Included: [...]

Inspectors wroteThe facility identified a census of 80 residents. The sample included 18 residents with five residents sampled for unnecessary medication review. Based on observation, record review and interview, the facility failed to ensure that Resident (R)11, R64, and R131 had an appropriate diagnosis for their antipsychotic (a class of medications used to treat psychosis and other mental emotional conditions) medication Seroquel (medication used to treat certain mental/mood conditions [such as schizophrenia a psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought]). This placed R11, R64, and R31 at risk for unnecessary antipsychotic medication administration and related side effects.