Delmar Gardens of Lenexa

Inspectors wroteBased on record review and interviews, the facility failed to provide R1's durable power of attorney (DPOA- a legal document that names a person to make healthcare decisions when the resident is no longer able to) with the Medicare Liability Notice, CMS 101123- Notice of Medicare Non-Coverage (NOMNC) prior to the last day of skilled coverage on 05/21/2026.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement an effective discharge plan in consideration with R1 and his Durable Power of Attorney (DPOA). The facility failed to ensure R1 safely discharged , including notifying his DPOA that he discharged and providing her with post-discharge instructions for R1.

Inspectors wroteThe facility reported a census of 162 residents, with 32 residents sampled. Based on observation, interview, and record review, the facility failed to ensure three of six medication carts observed were locked while unattended. This deficiency had the potential to affect 19 residents located on the 500 hallways and 29 residents located on the 600 hallways.

Inspectors wroteThe facility had a census of 162 residents. The sample included 32 residents with one resident reviewed for accommodation of needs related to call lights. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 98 call light was within her reach. Findings Included: - R98's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), hypertension (elevated blood pressure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). [...]

Inspectors wroteThe facility identified a census of 162 residents. The sample included three residents reviewed for beneficiary notifications. Based on interviews and record review, the facility failed to use the appropriate Advance Beneficiary Notice of Non-Coverage (ABN) Form CMS-10055 for resident (R) 194.

Inspectors wroteThe facility reported a census of 162 residents. The sample included 32 residents. Based on interview, observation and record review, the facility failed to protect the privacy of Resident (R) 10 and R96's personal and medical records.

Inspectors wroteThe facility had a census of 162 residents. The sample included 34 residents, with two reviewed for abuse. Based on observation, record review, and interview, the facility staff failed to identify a resident to resident altercation as potential abuse and report to the facility's Administrator as required.

Inspectors wroteThe facility had a census of 162 residents. The sample included 34 residents, with two reviewed for abuse. Based on observation, record review, and interview, the facility failed to identify a resident to resident altercation as potential abuse and initiate an investigation.

Inspectors wroteThe facility reported a census of 162 residents; the sample included 32 residents with one resident reviewed for tube feeding (administration of nutritionally balanced liquefied foods or nutrients through a tube). Based on observation, interviews, and record review, the facility failed to ensure Resident (R) 47s head of bed was elevated as his enteral feed formula was administered through R47's gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) by a feeding pump. Additionally, the facility failed to administer R47's enteral feed by the physician's order.

Inspectors wroteThe facility identified a census of 132 residents. The sample included 32 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 9s as needed diphenhydramine (an antihistamine used to treat allergy symptoms, hay fever, the common cold, insomnia, and motion sickness) medication order had a diagnosis or reason to administer medication.

Inspectors wroteThe facility reported a census of 162 residents. Twenty-six medication administrations were observed. Based on observation, interview and record review the facility failed to ensure a medication error rate of less than five percent when five errors were identified, resulting in a medication error rate of 19.23 percent.

Inspectors wroteThe facility reported a census of 162 residents. The sample included 32 residents. Based on interviews, observation and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) when providing direct care to a Resident (R) 3 with a coccyx (distal tip of the spine/tail-bone) wound and while providing direct care to R 120 and R 101 with open and scabbed wounds. Additionally, the facility failed to ensure adequate hand hygiene before and after personal care for R 3, and while passing ice between residents. [...]

Inspectors wroteThe facility had a census of 151 residents. The sample included 31 residents. The facility had six medication carts. Based on observation, interview, and record review, the facility failed to date Resident (R)53's insulin (a hormone which allows cells throughout the body to uptake glucose) flex pen when opened and failed to discard R15 and R346's insulin flex pen and R01's insulin vial when outdated. The facility further failed to discard expired stock medications. This deficient practice placed the affected residents at risk for ineffective medications.

Inspectors wroteThe facility had a census of 151 residents. The sample included 31 residents with one reviewed for dignity. Based on observation, record review, and interview the facility failed to treat Resident (R) 115 with dignity in one of five dining rooms, during the noon meal when staff stood over R115 while assisting him to eat. This placed the resident at risk for an undignified experience.

Inspectors wroteThe facility had a census of 151 residents. The sample included 31 residents with four reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to provide written notice for facility-initiated transfer to Resident (R) 68, R347, and R75 or their representatives, when they were transferred to the hospital. This placed the residents at risk for uninformed care choices.

Inspectors wroteThe facility had a census of 151 residents. The sample included 31 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 68, R347, and R75 or their representative with written information regarding the facility bed hold policy when they were transferred to the hospital. This placed the residents at risk of not being permitted to return and resume residence in the nursing facility.

Inspectors wroteThe facility had a census of 151 residents. The sample included 31 residents. Based on observation, interview, and record review the facility failed to ensure Residents (R) 87, R68, and R110 received a Preadmission Screening and Resident Review (PASRR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) to identify potential care needs related to a mental disorder (MD) or intellectual disability (ID). This placed the residents at risk for unidentified needs and inadequate care.

Inspectors wroteThe facility had a census of 151 residents. The sample included 31 residents. Based on observation, record review, and interview, the facility failed to revise the care plan with trauma triggers and coping strategies for Resident (R)50 who had post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) which placed the resident at risk for impaired care due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 151 residents. The sample included 31 residents, of which one was reviewed for mobility and positioning. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 53 received appropriate treatment and services to maintain and prevent a decline in mobility and ambulation. This placed the resident at risk for a decline in mobility and impaired independence.

Inspectors wrote- R70's Electronic Medical Record, (EMR) documented the resident had a diagnosis of hyperkalemia (greater than normal amount of potassium in the blood). R70's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) of 13, which indicated intact cognition. The MDS documented R70 required staff supervision with activities of daily living (ADLs). R70's Medication Care Plan, revised 10/02/22, instructed staff to administer her medications as the physician ordered. R70's EMR documented her potassium level was out of normal range (3.5-5.1millimoles per liter (mmol/L) of blood) on the following dates: 04/22/22-6.2 mmol/L 05/31/22-5.4 mmol/L The Physician Order, dated 06/09/2022, instructed staff to administer to R70 Lokelma (medication used to treat high levels of potassium in the blood) 5 gram (g) packet, daily. [...]

Inspectors wroteThe facility had a census of 118 residents. The sample included 25 residents, with one reviewed for smoking. Based on observation, record review and interview, the facility failed to develop a comprehensive care plan for smoking for Resident (R) 72. This placed the resident at risk for smoking related injury.

Inspectors wroteThe facility had a census of 118 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility failed to update the care plan with interventions for Resident (R) 51, and R111's falls, and R35 for behaviors. This practice placed the residents at risk for injury from falls and unmet care needs.

Inspectors wroteThe facility had a census of 118 residents. The sample included 25 residents with one reviewed for positioning. Based on observation, interview and record review the facility failed to ensure proper positioning and utilize a neck pillow or collar as care planned for sampled Resident (R) 101. This deficient practice placed the resident at risk for further decrease in range of motion.

Inspectors wroteThe facility had a census of 118 residents. The sample included 25 residents, with seven reviewed for accidents. Based on observation, record review, and interview, the facility failed to indentify and /or implement resident centered interventions to prevent falls for Resident (R) 51, and R111. This placed the residents at risk for further falls and injury.

Inspectors wroteThe facility had a census of 118 residents. The sample included 25 residents with one reviewed for medically related social service needs. Based on observation, interview and record review the facility failed to provide routine social services visits as care planned for Resident (R) 13. This deficient practice placed her at risk for further behavior and potential for rehospitalization.