Garden Terrace at Overland Park

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide adequate supervision and failed to ensure staff responded appropriately to door alarms to prevent the elopement of two cognitively impaired residents. Around 04:30 PM on 05/03/26, Resident (R) 1 and R2 exited the facility without staff knowledge or supervision. Certified Nurse Aide (CNA) M heard a door alarm and reset the alarm without checking to see what triggered the door alarm. At 05:20 PM, the facility learned R1 and R2 were with a community member at a store down the street from the facility. The facility staff did not realize R1 and R2 were out of the facility for approximately 45 minutes. The community member brought R1 and R2 back to the facility in her personal vehicle. This deficient practice placed R1 and R2 in immediate jeopardy.

Inspectors wroteThe facility identified a census of 141 residents. The sample included five residents, with three residents reviewed for dementia care. Based on record review and interviews, the facility failed to provide dementia care and services for Resident (R) 1 when the facility failed to assess, identify, record, respond to, and reassess R1's specific behaviors and triggers to promote an environment which supported R1's individualized care needs. This deficient practice resulted in ongoing and escalating behaviors, including aggression towards other residents.

Inspectors wroteThe facility identified a census of 141 residents. The sample included five residents, with three residents reviewed for dementia care. Based on record review and interviews, the facility failed to notify Resident (R) 1's provider of new or escalating behaviors.

Inspectors wroteThe facility identified a census of 145 residents. The sample included six residents, with six reviewed for abuse and neglect. Based on observation, interview, and record review, the facility failed to ensure cognitively impaired Resident (R) 2 and R3 remained free from resident-to-resident physical abuse by R1. On 09/30/25 at 07:55 AM, Certified Nurse Aide (CNA) N left the facility dining area unsupervised to assist another staff member. When CNA N returned to the dining area, he observed R2 with blood on his face while R1 (who had a history of wandering into resident rooms and behaviors including wanting to fight) stood nearby with blood on his hands. There was blood splashed on the window and table, and pooling on the floor near R2. CNA N asked R1 if he had hit R2, and R1 stated he had. CNA N asked R1 to walk away and allowed R1 to leave the area unsupervised. [...]

Inspectors wroteThe facility identified a census of 147 residents. The sample included 31 residents, with three residents reviewed for dignity. Based on observation, interview, and record review, the facility failed to provide a dignified care environment for Residents (R) 127, R137, R4, R91, R8, and R11. This deficient practice placed the residents at risk for impaired dignity and quality of life. Findings Included: - On 05/12/25 at 07:23 AM, R127 (a severely cognitively impaired resident) stood in the first room right off the dining room. R127 had her pants and briefs pulled down and was feeling the inside of her briefs. R127 was not in her bedroom. On 05/12/25 at 07:23 AM, R127 stood in the first room right off the dining room. R127 had her pants and briefs pulled down and was feeling the inside of her briefs. R127 was not in her bedroom. [...]

Inspectors wroteThe facility identified a census of 148 residents. The sample included 29 residents, with five sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 37, R93, R248, and R90 were free from antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication use without an appropriate indication for use or a gradual dose reduction (GDR - tapering of a medication dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued). The facility failed to ensure the physician provided the risk versus benefit statement for the continued use of antipsychotic medications. [...]

Inspectors wrote- R34's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), history of cervical vertebra fracture (broken bone of the spinal column), history of falls, and unsteadiness on her feet. The Annual Minimum Data Set (MDS) dated 12/06/24 documented a Brief Interview of Mental Status (BIMS) score of 99 and a staff interview was conducted, which indicated severely impaired cognition. The MDS documented R34 was independent with walking 10 feet and 50 feet. R34 required partial to moderate assistance with walking 150 feet. The Quarterly MDS dated 04/23/25 documented a BIMS score of 99 and a staff interview was conducted, which indicated severely impaired cognition. [...]

Inspectors wrote- R23's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), muscle weakness, and cerebrovascular accident (CVA - stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The admission Minimum Data Set (MDS) dated 10/15/24 documented a Brief Interview of Mental Status (BIMS) score of three, which indicated severely impaired cognition. The MDS documented R23 had no behavioral symptoms during the observation period. The Quarterly MDS dated 04/10/25 documented a BIMS score of four, which indicated severely impaired cognition. The MDS documented that R23 had no behavioral symptoms during the observation period. [...]

Inspectors wroteThe facility identified a census of 148 residents. The sample included 29 residents, with five sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure that the Consultant pharmacist (CP) identified and reported Resident (R) 37 and R90's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication use without an appropriate indication for use. The facility failed to ensure the CP recommended a gradual dose reduction (GDR - tapering of a medication dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) for R37 and R90's antipsychotic medication. [...]

Inspectors wroteThe facility identified a census of 147 residents. The sample included 31 residents, with five reviewed for immunization status. Based on record reviews and interviews, the facility failed to obtain consent or declinations for the Pneumococcal Conjugate Vaccine (PCV20 - vaccination for bacterial infections) pneumococcal (type of bacterial infection) vaccination for Resident (R) 37 R93, R90, R248, and R143 This placed the residents at increased risk for complications related to pneumonia.

Inspectors wroteThe facility identified a census of 147 residents. The sample included 31 residents, with two residents sampled for reasonable accommodations of needs. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 25's food preferences were met, due to nursing staff taking dietary items away from the tray. This deficient practice placed R25 at risk for impaired physical, mental, and psychosocial well-being.

Inspectors wroteThe facility identified a census of 147 residents. The sample included 31 residents, with one reviewed for notification of changes. Based on observation, record review, and interviews, the facility failed to notify Resident (R) 198's physician of changes related to his head injury from staff-assisted cares. This deficient practice resulted in a delay in acute medical treatment. Findings Included: - The Medical Diagnosis section within R198's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), acute femur (upper leg bone) fracture (broken bone), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). [...]

Inspectors wroteThe facility identified a census of 147 residents. The sample included 31 residents, with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on interview and record review, the facility failed to issue Center for Medicare/Medicaid Services (CMS) Notification of Medicare Non-Coverage Form 10123 (NOMNC - the form used to notify Medicare A participants of their rights to appeal and the last covered date of participants of potential financial liability when a Medicare Part A episode ends) with the required information for Resident (R) 199. This failure placed the resident at risk for decreased autonomy and impaired decision-making.

Inspectors wroteThe facility identified a census of 147 residents. The sample included 31 residents, with 31 residents reviewed for comprehensive care plans. Based on observation, record review, and interviews, the facility failed to develop a comprehensive care plan for Resident (R) 46 for person-centered preferences. The facility also failed to develop a comprehensive care plan for R82 for respiratory therapy. These deficient practices placed these residents at risk for impaired care due to uncommunicated care needs.

Inspectors wroteThe facility identified a census of 147 residents. The sample included 31 residents, with 31 residents reviewed for care plan for resident centered revisions. The facility failed to revise the care plan to include resident-centered functional abilities for Resident (R) 23. This placed the resident at risk for unmet care needs.

Inspectors wroteThe facility identified a census of 147 residents. The sample included 31 residents, with six residents reviewed for activities of daily living (ADL). Based on observation, record review, and interviews, the facility failed to provide the necessary assistance with personal hygiene for Resident (R) 46. This deficient practice placed R46 at risk for poor hygiene, decreased self-esteem, and impaired dignity.

Inspectors wroteThe facility identified a census of 147 residents. The sample included 31 residents with one resident reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to follow a physician's order to apply thrombo-embolic-deterrent hose (TED hose - specialized compression stockings designed to help manage swelling of the feet/legs) in the mornings for edema (swelling resulting from an excessive accumulation of fluid in the body tissues). This deficient practice placed R90 at risk for increased edema, pain, and skin-related difficulties. Findings Included: [...]

Inspectors wrote- R122's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and muscle weakness. The admission Minimum Data Set (MDS) dated 05/08/24 documented a Brief Interview of Mental Status (BIMS) score of seven, which indicated severely impaired cognition. The MDS documented R122 was not at risk of the development of pressure-related injuries. The MDS documented R122 had a pressure-reducing device on her bed. The Quarterly MDS dated 02/07/25 documented a staff interview was conducted and R122 had moderately impaired cognition. The MDS documented that R122 was not at risk of development of a pressure-relayed injury. [...]

Inspectors wroteThe facility identified a census of 147 residents. The sample included 31 residents, with four residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 89's braces to both knees were applied. This deficient practice placed the resident at risk for discomfort and decreased range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension).

Inspectors wroteCitation Text for Tag 0690, Regulation FF16 [NAME], [NAME] The facility identified a census of 147 residents. The sample included 31 residents, with three sampled residents reviewed for bowel and bladder incontinence and catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care. Based on observation, record review, and interview, the facility failed to ensure staff provided appropriate treatment and services to prevent potential urinary tract infections (UTI - an infection in any part of the urinary system) for Resident (R) 11 when staff failed to ensure R11's catheter bag (a urine drainage bag that collects urine from a catheter, a tube inserted into the bladder to allow urine to drain) was drained each shift and as needed. This placed R11 at risk of complications, infection, and further urinary problems.

Inspectors wroteThe facility identified a census of 147 residents. The sample included 31 residents, with two residents reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure there was a physician indication for oxygen administration for Resident (R) 82 and failed to ensure the oxygen tubing was stored in a sanitary manner to and contamination. This placed R82 at increased risk for respiratory infection and complications.

Inspectors wroteThe facility identified a census of 147 residents. The sample included 31 residents with one reviewed for competent staffing. Based on observation, record review, and interviews, the facility failed to ensure staff possessed the appropriate skills and knowledge to safely provide direct care and nursing services related to Resident (R) 198's care needs. These deficient practices resulted in preventable injuries and delayed medical treatment. Findings Included: - On 05/15/25 a review of Certified Nurses Aide (CNA) Q personnel file revealed she received a Corrective Action Form on 11/04/25. The counseling form was a final notice counseling related to an injury-related accident that occurred with R198 on 11/01/24. [...]

Inspectors wroteThe facility identified a census of 148 residents. The sample included 29 residents, with five sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 93, and R248's physician-ordered parameters were obtained and monitored prior to administration of their beta-blocker (medications that help lower blood pressure and heart rate) antihypertensive (a class of medication used to treat high blood pressure) medications. The facility failed to ensure R93's diclofenac gel (topical medication used to treat pain and inflammation) order included the required dosage amount. These deficient practices placed R93 and R248 at risk of unnecessary medication administration and related complications.

Inspectors wrote- R11's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) with agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), retention of urine (a condition in which you are unable to empty all the urine from your bladder), and chronic kidney disease (the kidneys are damaged and can't filter blood properly, leading to a buildup of waste and fluid in the body). R11's admission Minimum Data Set (MDS) dated 02/26/25 documented R11 had a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R11 displayed signs and symptoms of delirium (sudden severe confusion, disorientation, and restlessness) including inattention and disorganized thinking. [...]

Inspectors wroteThe facility identified a census of 154 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to ensure cognitively impaired Resident (R) 1 remained free from physical abuse. On 10/09/24 at approximately 08:25 AM, Licensed Nurse (LN) G overheard Certified Nurse Aide (CNA) M tell R1 she could not have any sugar because she was diabetic (a condition when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) and R1 became upset. LN G turned around and observed R1 hit CNA M in the stomach. LN G observed CNA M react to R1 by making a fist and punching R1 in the left upper arm. LN G immediately notified Administrative Nurse D who removed CNA M from the building and suspended her pending investigation. R1 complained of left upper arm pain. [...]

Inspectors wroteThe facility identified a census of 156 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to provide adequate supervision to prevent Resident (R) 1, a cognitively impaired resident who had a history of making comments about leaving and was at risk for falls, from eloping from the facility. On 07/15/24 at 01:20 PM, Housekeeping Staff U notified Licensed Nurse (LN) G that R1 made a statement to her that he wanted to go home. LN G retrieved a vital sign machine then went to R1's room to obtain his vital signs and noted he was not in his room. LN G asked other staff members if they had seen R1, but they had not. LN G informed Administrative Nurse D that R1 was missing at 01:21 PM. A Dr. Walker code was called to inform staff of a missing resident and a resident count began while the facility was searched. [...]

Inspectors wroteThe facility identified a census of 155 residents. The sample included three residents reviewed for dementia (a progressive mental disorder characterized by failing memory, and confusion) care. Based on observations, record review, and interviews, the facility failed to provide dementia care and services for Resident (R) 1 when the facility failed to ensure staff utilized resident-specific interventions for behaviors. This deficient practice created an environment that affected R1's ability to maintain his highest practicable level of physical, mental, and psychosocial well-being.

Inspectors wroteThe facility identified a census of 155 residents. The sample included three residents reviewed for activities of daily living (ADL). Based on observation, record review, and interview, the facility failed to ensure Resident (R)1 received the necessary assistive care and services with ADL to maintain her highest practicable ability and promote independence. This placed R1 at risk for injury, pain, and decreased ability to perform ADL.

Inspectors wroteThe facility had a census of 153 residents. The sample included 30 residents and five Certified Nurse Aide's (CNA) reviewed for performance evaluations and required in-service training. Based on record review and interview, the facility failed to ensure three of the five CNA staff reviewed had the required 12 hours of in-service education per year. This placed the residents at risk for inadequate care.

Inspectors wroteThe facility identified a census of 153 residents. The facility failed to ensure that staff members properly secured their hair in a hairnet when preparing and serving residents' food. The facility failed to ensure proper hand hygiene during mealtime. This placed all residents who ate food from the facility at risk for food borne illness.

Inspectors wroteThe facility had a census of 153 residents. Five Certified Nurse Aides (CNA) were reviewed for required in-service training. Based on record review and interview, the facility failed to provide CNA PP the required in-service education for dementia (progressive mental disorder characterized by failing memory, confusion) care. This placed the residents at risk for decreased quality of life and/or inadequate care.

Inspectors wroteThe facility identified a census of 153 residents. The sample included 30 residents. Based on observation, record review, and interview, the facility failed to secure the soiled utility room, which contained a hazardous material, to be kept out of reach of cognitively impaired, independently mobile residents. The facility additonally failed to ensure staff followed care planned interventions for Resident (R)145 to prevent accidents and falls. These deficient practices placed these residents at risk for preventable accidents and injuries.

Inspectors wroteThe facility identified a census of 153 residents and one resident with COVID-19 (highly contagious respiratory virus). The sample included 30 residents. The facility failed to ensure staff did appropriate hand hygiene during Resident (R) 115's catheter (tube inserted into the bladder to drain the urine into a collection bag) care. The facility failed to ensure staff wore the facility-mandated personal protective equipment (PPE- masks) appropriately. This deficient practice placed residents at risk related to infectious diseases.

Inspectors wroteThe facility identified a census of 153 residents. The sample included 30 residents. Based on observation, record review, and interview the facility failed to ensure dignified care for Resident (R) 14, R30 and R109. This placed the residents at risk for decreased self-esteem and impaired psychosocial well-being.

Inspectors wroteThe facility had a census of 153 residents. The sample included 30 residents with two reviewed for accommodation of needs. Based on observation, record review and interview the facility failed to provide and use foot pedals during wheelchair transports for Resident (R)17 and R45. This placed the resident at risk for preventable accidents. Findings Included: -The Medical Diagnosis section within R17's Electronic Medical Records (EMR) included diagnoses of dementia, dysphagia (difficulty swallowing), muscle weakness, osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), and history of fractures (broken bone). R17's Quarterly Minimum Data Set (MDS) completed 06/09/23 noted a Brief Interview for Mental Status (BIMS) score of zero indicating severe cognitive impairment. [...]

Inspectors wroteThe facility identified a census of 153. The sample included 30 residents. Based on record review and interview, the facility failed to provide a written notification of transfers with the required information to Resident (R) 3 or the durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to) in a practicable amount of time. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for R3.

Inspectors wroteThe facility identified a census of 153 residents. The sample included 30 residents with four residents reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide a bed hold notice when Resident (R) 115 was hospitalized . This deficient practice placed R115 at risk of uninformed choices.

Inspectors wroteThe facility identified a census of 153 residents. The sample included 30 residents with five reviewed for activities of daily living (ADLs). Based on observations, interviews, and record reviews, the facility failed to provide the required ADL assistance to Resident (R)41. The facility additionally failed to provide R41's special adaptive equipment (small-sized spoon) for her meals. This deficient practice placed R41 at risk for complications related to weight loss and physical decline. Findings Included: [...]

Inspectors wroteThe facility identified a census of 153 residents. The sample included 30 residents. Based on observation, record review, and interview the facility failed to ensure staff provided the care and services as directed in the plan of care for Resident (R)41. The deficient practice placed R41 at risk preventable aspiration and respiratory illness. The facility also failed to ensure that physician-ordered tubigrips (elasticated tubular bandage used reduce swelling) were applied to R45 for skin integrity. This deficient practice put R45 at increased risk for excess fluid retention and skin integrity issues. Findings Inlcuded: [...]

Inspectors wroteThe facility identified a census of 153 residents. The sample included 30 residents with one resident reviewed for limited range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). Based on observation, record review, and interviews, the facility failed to implement a ROM program to help maintain and prevent a potential decrease in ROM/mobility for Resident (R) 143. The facility further failed to ensure R45's righthand splint was applied to prevent contractures. This deficient practices placed these residents at risk of loss of ability to perform activities of daily living (ADLs) and development of contractures.

Inspectors wroteThe facility identified a census of 153 residents. The sample included 30 residents with three residents reviewed for catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) and urinary tract infection (UTI-an infection in any part of the urinary system). Based on observation, record review, and interviews, the facility failed to provide appropriate treatment for Resident (R) 115 with an indwelling catheter (tube inserted into the bladder to drain urine into a collection bag) and a nephrostomy tube (an artificial opening between the kidney and the skin which allows urine to drain from the body) when the facility failed to prevent the drainage bags from resting on the floor, failed to have an anchor for the catheter tubing to prevent pulling and injury, and failed to maintain the urine drainage bag below the bladder. [...]

Inspectors wroteThe facility identified a census of 153 residents. The sample included 30 residents with one resident reviewed for pain management. Based on observation, record review, and interviews, the facility failed to recognize, assess, and treat Resident (R) 94 for pain. This placed R94 at risk of ongoing pain, impaired psychosocial wellbeing, and diminished quality of life.

Inspectors wroteThe facility identified a census of 153 residents. The sample included 30 residents with 30 reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care. Based on record review, interviews, and observations, the facility failed to provide dementia care and services in order attain and maintain the residents highest practicable quality of life for Residents (R)17, R41, and R45. This deficient practiced placed the residents at risk for impaired quality of life and decreased psychosocial wellbeing. Findings Included: -The Medical Diagnosis section within R17's Electronic Medical Records (EMR) included diagnoses of dementia, dysphagia (difficulty swallowing), muscle weakness, osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), and history of fractures (broken bone). [...]

Inspectors wroteThe facility identified a census of 153. The sample included 30 residents with five sample residents reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure the Consultant Pharmacist (CP) identified and reported that Resident (R)133 had an inappropriate indication and lacked a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of Seroquel (antipsychotic). This deficient practice placed R133 at risk of unnecessary medication administration and possible adverse side effects.

Inspectors wroteThe facility identified a census of 153. The sample included 30 residents with five sample residents reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure Resident (R)133 had an appropriate indication for use, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of Seroquel (antipsychotic). This deficient practice placed R133 at risk of unnecessary medication administration and possible adverse side effects.

Inspectors wroteThe facility had a census of 111 residents. Based on observation, record review, and interview the facility failed to provide a backflow device (unwanted flow of water in the reverse direction) or a two-inch air gap for the drainage system of the kitchen ice machine, used by the 111 residents who resided in the facility. This placed the affected residents at risk to receive contaminated ice. Findings Included: - On 03/02/22 at 11:15 AM, observation revealed three white plastic drainpipes extended from the back of the ice machine and inserted into a six inch white plastic drainpipe at the floor drain. The ice machine drainage system had no backflow device or two-inch air gap. On 03/02/22 at 11:37 AM, Dietary Staff BB verified the ice machine drainage system did not have a backflow device, or two-inch air gap to prevent possible backflow of contamination into the ice supply. [...]

Inspectors wroteThe facility had a census of 111 residents. The sample included 23 residents with 11 reviewed for accidents/falls. Based on observation, record review and interview, the facility failed to notify the physician of low blood pressures for one sampled resident, Resident (R) 57. This placed the resident at risk for continued low blood pressures and adverse medication side effects.

Inspectors wroteThe facility had a census of 111 residents. The sample included 23 residents, with three reviewed for Beneficiary Notices. Based on record review and interview, the facility failed to provide the three sampled residents, Resident (R) 13, R14, and R214 (or their representative) the completed Notice of Medicare Non-Coverage (NOMNC) Form 10123 Centers for Medicare and Medicaid Services (CMS), and R214 the completed Skilled Nursing Facility Advanced Beneficiary Notice of Non Coverage (SNF ABN) Form 10055 .

Inspectors wroteThe facility had a census of 111 residents. The sample included 23 residents with one reviewed for hospice (a type of health care that focused on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R) 41. This placed R41 at risk for inappropriate end of life cares.