Overland Park Post Acute

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff possessed the appropriate skills and knowledge to safely provide direct care and nursing services related to Resident (R) 1's care needs.

Inspectors wroteBased on record review, interview, and observation, the facility failed to identify the lack of required staff, resulting in a fall for Resident (R) 2 as an allegation of neglect and report to the State Agency (SA) as required.

Inspectors wroteBased on interviews, observations, and record review, the facility failed to ensure safe activities of daily living care while helping Resident (R) 2 get dressed for the day when there was only one staff member assisting R2 and R2 rolled off the bed and hit his head, resulting in a laceration, a hematoma, and being set out to the hospital for evaluation.

Inspectors wroteBased on interview, record review, and observation, the facility failed to ensure Resident (R) 1 remained free from significant medication errors when staff administered fast acting insulin instead of the ordered long-acting insulin.

Inspectors wroteBased on record review and interviews, the facility failed to prevent medication errors when they failed to reconcile pain medication orders from the hospital on readmission for Resident (R) 1.

Inspectors wroteThe facility identified a census of 124 residents. The sample included five residents with three residents reviewed for wound care. Based on observation, record review, and interviews, the facility failed to transcribe and follow the wound care physician's orders for Resident (R) 1 related to her diabetic foot ulcer (an open wound on the foot caused by poor circulation, nerve damage, and high blood sugar).

Inspectors wroteThe facility identified a census of 126 residents. The sample included four residents with one reviewed for accommodation of needs. Based on observation, record review, and interview, the facility failed to provide necessary foot care and services for Resident (R) 1.

Inspectors wroteThe facility identified a census of 126. The sample included four residents with one sample for respiratory services. Based on observation, record review, and interviews, the facility failed to obtain and provide a physician-ordered continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) machine for Resident (R) 1.

Inspectors wroteThe facility identified a census of 126. The sample included four residents with one sampled for pharmacy services. Based on observation, record review, and interviews, the facility failed to provide physician ordered Mounjaro (medication used to manage type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin)) to Resident (R) 1.

Inspectors wroteThe facility identified a census of 106 residents. The sample included three residents reviewed for falls and accidents. Based on observation, record review, and interview, the facility failed to investigate, determine causative factors, and implement relevant interventions to prevent further falls for Resident (R) 1, after R1 was found lying face down on the floor, at the bedside, on 11/08/24. Subsequently, R1 had another fall from the bed on 04/10/25, which resulted in a left femur (thigh bone) fracture and placed the resident at risk for further injuries and related pain.

Inspectors wroteThe facility identified a census of 87 residents. The facility had one main kitchen and three dining areas. Based on observation, record review, and interview the facility failed to ensure the director of food and nutrition services had the required qualifications of a certified dietary manager (CDM). This placed residents at risk for unmet dietary and nutritional needs.

Inspectors wroteThe facility identified a census of 87 residents. The facility had one main kitchen. Based on observation and interview, the facility failed to ensure staff stored food items in accordance with the professional standards for food service safety. The facility failed to ensure the high-temperature dishwasher was in proper working condition to wash and sanitize kitchenware and dishes. This placed residents at risk of foodborne illness and cross-contamination (the transfer of harmful substances to food).

Inspectors wroteThe facility identified a census of 87 residents. The sample included 20 residents. Based on interviews and record reviews, 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. This failure placed all 87 residents residing in the facility at risk for impaired care. Findings Included: - An inspection of the Facility Assessment dated 04/18/24 provided by the facility revealed the following: The assessment did not identify the specific staffing levels needed for each unit and identify the number of Registered Nurses (RN), Licensed Nurses (LPN/LVN), Certified Medication Aides (CMA), and Certified Nurse Aides (CNA) needed for each unit, patient acuity, and census. The assessment lacked the staffing levels required for each shift. [...]

Inspectors wroteThe facility identified a census of 87 residents. The facility identified eight residents on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record reviews, observations, and interviews, the facility failed to implement signage or indicators within the physical environment to alert staff and visitors of the required EBP. The facility further failed to provide a Legionella (Legionella is a bacterium that can cause pneumonia in vulnerable populations) water management program to assess and mitigate the risk of Legionella and failed to maintain water temperatures to effectively clean and disinfect laundry. [...]

Inspectors wroteThe facility identified a census of 87 residents. Based on record review and interviews, the facility failed to ensure agency staff received the required communication training. This placed the residents at risk for impaired care and decreased quality of life.

Inspectors wroteThe facility identified a census of 87 residents. Based on record review and interviews, the facility failed to ensure agency staff received the required resident rights training. This placed the residents at risk for impaired care and decreased quality of life.

Inspectors wroteThe facility identified a census of 87 residents. Based on record review and interviews, the facility failed to ensure agency staff received the required infection control training. This placed the residents at risk for impaired care and decreased quality of life.

Inspectors wroteThe facility identified a census of 87 residents. The sample included 20 residents. Based on interviews and record reviews, the facility failed to provide activities on the weekends that met the residents' interests, social needs, and preferences. This placed the residents at risk for boredom, isolation, and decreased quality of life.

Inspectors wroteThe facility identified a census of 87 residents. The sample included 20 residents with five sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure a medication regimen review (MRR) was completed at least monthly for Resident (R) 31, R79, R28, R39, and R50. The facility further failed to ensure the Consultant Pharmacist (CP) identified and made recommendations for a Center for Medicaid and Medicare (CMS) approved indication or a gradual dose reduction (GDR) for antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medications for R31 and R28. The facility failed to ensure the CP identified and reported R79 and R28's diclofenac (Voltaren- a topical medication that reduces pain and inflammation) lacked a dosage. [...]

Inspectors wroteThe facility identified a census of 87 residents. The sample included 20 residents. One resident was sampled for reasonable accommodations of resident needs and preferences. Based on observation, record review, and interview, the facility failed to ensure Resident (R)44's built-up utensils (foam grip on regular utensils), and a divided plate was provided. This deficient practice left R44 vulnerable to unmet care needs due to the inability to feed herself.

Inspectors wroteThe facility identified a census of 87 residents. The sample included 20 residents with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interviews, the facility failed to provide form CMS-10055, Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Non-coverage (ABN) which included the estimated cost for continued services for skilled services to the resident or their representative for Resident (R) 18, R33, and R39. This deficient practice placed three residents at risk for uninformed decisions.

Inspectors wroteThe facility identified a census of 87 residents. The sample included 20 residents with one resident reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide written notice of transfer/discharge as soon as practicable for Resident (R) 39's facility-initiated transfers. This deficient practice placed R39 at risk of uninformed choices and miscommunication regarding care needs.

Inspectors wroteThe facility reported a census of 87 residents. The sample included 20 residents with 20 reviewed for Minimum Data Set (MDS) completion. Based on interviews and record review, the facility failed to complete a quarterly assessment no more than 92 days from the last MDS for Resident (R)84 and R17. This deficient practice placed the residents at risk for unidentified and unmet care needs.

Inspectors wroteThe facility identified a census of 87 residents. The sample included 20 residents with seven residents reviewed for activities of daily living (ADL) care. Based on observation, record review, and interviews, the facility failed to ensure bathing was provided for Resident (R) 44 who required assistance from staff to complete the care. This deficient practice placed resident R44 at risk for complications related to poor hygiene and impaired dignity.

Inspectors wroteThe facility identified a census of 87 residents. The sample included 20 with six reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on interviews, record review, and observations, the facility failed to ensure Resident (R) 37, and R26s' low air-loss mattress pump, used to prevent pressure ulcers, was set and functioning for adequate pressure relief. This deficient practice placed the residents at risk for complications related to skin breakdown and pressure ulcers. Findings Included: [...]

Inspectors wroteThe facility identified a census of 87 residents. The sample included 20 residents with four residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)26, R50, and R9 were provided the services and treatment to prevent worsening of contractures (abnormal permanent fixation of a joint or muscle). This deficient practice placed the residents 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 wroteThe facility identified a census of 87 residents. The sample included 20 residents with one sampled resident reviewed for dialysis (a procedure where impurities or wastes were removed from the blood). Based on observation, record review, and interview, the facility failed to ensure ongoing communication and collaboration with the dialysis facility for dialysis care and services regarding Resident (R) 67's health status with each procedure. The facility additionally failed to weigh R67 before his dialysis appointments on eight occasions. This deficient practice placed R67 at risk for complications related to end-stage renal failure. Findings Included: - The Medical Diagnosis section within R67's Electronic Medical Records (EMR) noted diagnoses of major depressive disorder (major mood disorder), end-stage renal failure, and muscle weakness. [...]

Inspectors wroteThe facility identified a census of 87 residents. The sample included 20 residents with two residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure that Resident (R)37 had a safety assessment for the use of side rails, consent for the use of the side rails, and failed to ensure the resident and/or responsible party were advised of the risks and/or benefits of the use of the side rails. This placed R37 at risk for uninformed decisions and impaired safety related to the risks associated with the use of side rails. Findings Included: [...]

Inspectors wroteThe facility identified a census of 87 residents. The sample included 20 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure antihypertensive (medication used to treat high blood pressure) medication was administered per the physician-ordered parameters for Resident (R) 39 and the facility further failed to ensure dosing instructions for Voltaren (non-steroidal anti-inflammatory drug [NSAID]) for R28 and R79. These deficient practices placed these residents at risk for unnecessary medication use, side effects, and physical complications.

Inspectors wroteThe facility identified a census of 87 residents. The sample included 20 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 28, R31, and R79 had a Center for Medicare and Medicaid Services (CMS) approved indication for the use of an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) or the required physician documentation. The facility further failed to ensure a gradual dose reduction (GDR) was attempted or documented as contraindicated by the physician with a supporting rationale. These deficient practices placed these residents at risk for unnecessary medications and adverse side effects.

Inspectors wroteThe facility identified a census of 87 residents. The sample included 20 residents with one resident 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) 24 by hospice. This deficient practice created a risk of missed or delayed services and inadequate end-of-life care for R24.

Inspectors wroteThe facility identified a census of 87 residents. The sample included 20 residents. Based on observation, record review, and interviews, the facility failed to provide mail delivery on Saturdays. Findings Included: - On 09/10/24 at 03:01 PM the Resident Council members reported that the facility did not provide mail services for the residents on Saturdays. The council reported the mail was stored over the weekend at the east nurse's station and distributed the following Monday. They stated that the weekend activity staff that used to pass it out stopped coming. On 09/10/24 at 01:05 PM Activities Staff Z stated she worked Monday through Friday. She stated that she previously had an assistant who provided activities and mail on weekends, but he no longer worked weekends. She stated she tried to come in on weekends but was often unable to do so on most weekends. [...]

Inspectors wroteThe facility identified a census of 89 residents. The sample included three residents. Based on observation, record review, and interview the facility failed to ensure Resident (R) 1 remained free from abuse when Certified Nurse Aide (CNA) M tried to pull the call light out of R1's hands and pulled R1 from the bed onto the floor during the struggle. This abuse placed R1 at risk of pain, injury, and ongoing abuse.

Inspectors wroteThe facility identified a census of 102 residents. The sample included five residents reviewed for weight loss. Based on record review, observation, and interview, the facility failed to monitor oral intake, failed to ensure routine and consistent weight monitoring, and failed to implement further interventions such as fortified foods until after a significant weight loss for Resident (R)1. The facility further failed to ensure R1 received the necessary adaptive utensils required for eating. This deficient practice resulted in a loss of 15.57 percent in three months and placed R1 at risk for further loss and malnutrition.

Inspectors wroteThe facility identified a census of 102 residents. The sample included five residents. Based on record review, interview, and observation, the facility failed to ensure nursing services met the standard of care when staff failed to obtain physician-ordered lab work for Resident (R)1 including lab work to monitor for serious side effects of R1's atypical antipsychotic (class of medications used to treat major mental conditions that cause a break from reality). This placed R1 at risk for impaired quality of care and adverse effects.

Inspectors wroteThe facility had a census of 112 residents. The sample included 26 residents, with five reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to identify and implement preventative measures to prevent pressure ulcers and promote healing of pressure injuries for Resident (R) 46, who developed unstageable pressure ulcers on both of his heels and a stage two (shallow with a reddish base and have a break in the top two layers of the skin) pressure ulcer on his buttock.

Inspectors wroteThe facility had a census of 112 residents. The sample included 26 residents with 12 residents reviewed for activities of daily living (ADLs). Based on observation, record review and interview, the facility failed to provide scheduled bathing for five sampled residents, Resident (R) 29, R94, R5, R31 and R101. This placed the residents at risk for poor hygiene and skin issues.

Inspectors wroteThe facility had a census of 112 residents. The sample included 26 residents. Based on observation, record review, and interview the facility failed to provide an accurate reconciliation of controlled drugs at the beginning and end of daily worked shifts for three of seven medication carts. This placed residents at risk for misappropriation of medications by staff.

Inspectors wroteThe facility had a census of 112 residents. Based on observation, interview, and record review, the facility failed to label insulin (hormone which allows cells throughout the body to uptake glucose) pens with the date opened for Resident (R)102 and R22, failed to discard an expired insulin pen for R112, and failed to discard expired stock medications on one of two halls. This placed the affected residents at risk for ineffective medication regimen.

Inspectors wroteThe facility had a census of 112 residents. Based on observation, interview, and record review the facility failed to implement appropriate infection control practices when cleaning a clostridium difficile (C-Diff: germ that causes serious diarrhea and other problems) isolation room on one of eight resident halls, failed to ensure nursing staff performed hand hygiene between glove changes when providing wound care for Resident (R) 16, and failed to remove soiled linens and urine containers from R16's room. These deficient practices placed the residents at increased risk for infections and transmission of a communicable disease.

Inspectors wroteThe facility had a census of 112 residents. The sample included 26 residents. Based on observation, interview, and record review the facility failed to accommodate the needs of Resident (R) 16 when staff failed to ensure access to his closet and instead, piled clothing on his bed. This placed R16 at risk for impaired comfort and decreased psychosocial wellbeing.

Inspectors wroteThe facility reported a census of 112 residents. The sample included 26 residents with nine reviewed for abuse. Based on observation, interview and record review, the facility failed to prevent the misappropriation of medications for Resident (R) 54 when R54's lorazepam (controlled substance schedule IV for anxiety) was not located in the facility's narcotic locked cabinet, or in the facility. This placed the resident at risk for ineffective /delayed treatment. Findings Included: [...]

Inspectors wroteThe facility had a census of 112 residents. The sample included 26 residents, with one reviewed for a Pre-admission Screening and Resident Review (PASARR) for individuals with mental disorders and individuals with intellectually disability. Based on record review and interview, the facility failed to ensure completion of a PASSAR for Resident (R) 101. This placed the resident at risk for unidentified care needs and services.

Inspectors wroteThe facility had a census of 112 residents. The sample included 26 residents. Based on observation, record review and interview the facility failed to develop and implement a diabetic care plan for sampled resident, Resident (R) 8 and a dialysis care plan R215. This placed the residents at risk to not receive appropriate cares and treatments.

Inspectors wroteThe facility had a census of 112 residents. The sample included 26 residents with six reviewed for accidents. Based on observation, record review, and interview. the facility failed to revise the care plan with interventions to prevent falls for one sampled resident, Resident (R) 5, who had multiple falls. This placed the resident at risk for further falls.

Inspectors wroteThe facility had a census of 112 residents. The sample included 26 residents. Based on observation, record review and interview, the facility failed to obtain laboratory tests as physician ordered upon admission for two sampled residents, Resident (R) 29 and R38. This placed the residents at risk for lack of monitoring and continued or worsened health problems.

Inspectors wroteThe facility had a census of 112 residents. The sample included 26 residents with six reviewed for accidents. Based on observation, record review, and interview. the facility failed to provide a safe environment and failed to implement resident centered interventions for one sampled resident, Resident (R) 5, who received a burn from a cigarette and had multiple falls. This placed the resident at risk for further falls and injury.

Inspectors wroteThe facility had a census of 112 residents. The sample included 26 residents with eight reviewed for nutrition. Based on observation, record review and interview, the facility failed to monitor meal and supplement intake as ordered by the physician and recommended by the Registered Dietician (RD) for an insidious (gradual with potential for harm) weight loss for one sampled resident, Residents (R) 97. This placed the resident at risk for nutritional problems and continued weight loss.

Inspectors wroteThe facility had a census of 112 residents. The sample included 26 residents with three reviewed for dialysis (the process of removing excess water and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, interview and record review the facility failed to communicate and collaborate care with the treating dialysis center, failed to care plan dialysis related care, and failed to provide a renal diet as ordered for Resident (R) 215. This deficient practice placed R215 at risk for inadequate care, services and treatment for a dialysis resident.

Inspectors wroteThe facility had a census of 112 residents. The sample included 26 residents with 13 reviewed for medication concerns. Based on observation, interview, and record review the facility failed to assess or notify the physician, as ordered, of blood sugars outside of physician ordered parameters for Residents (R) 35, R8, and R94. This deficient practice placed the residents at risk of inadequate control of their blood sugar without physician intervention regarding insulin (hormone which regulates the amount of glucose(sugar) in the blood).

Inspectors wroteThe facility had a census of 56 residents. The sample included 15 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to notify the physician of elevated blood sugars out of the physician ordered parameters for Resident (R) 8 and R94 placing the residents at risk for continued elevated blood sugars and adverse side effects.

Inspectors wroteThe facility had a census of 96 residents. The sample included 21 residents, with ten reviewed for Activities of Daily Living (ADLs). Based on observation, record review, and interview the facility failed to provide necessary bathing to maintain appropriate grooming and personal hygiene for four of ten sampled residents, Resident (R) 43, R60, R15, and R198.

Inspectors wroteThe facility had a census of 96 residents. Based on observation, record review, and interview the facility failed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections on two of five halls, when housekeeping staff failed to change gloves, wash hands, and leave Betco AF 315 (disinfectant cleaner) on for the proper kill time, during cleaning of a resident's room on contact isolation for Extended spectrum beta-lactamases (ESBL- a type of enzyme or chemical produced by some bacteria) in the resident's urine. The facility staff failed to apply personal protective equipment (PPE) prior to entering the same room.

Inspectors wroteThe facility had a census of 96 residents. The sample included 21 residents with three reviewed for Beneficiary Notices. Based on record review and interview, the facility failed to provide two of three sampled residents, Resident (R) 201 and R77 or their representative, the completed Notice of Medicare Non-Coverage Form (NOMNC) 10123 Centers for Medicare and Medicare Services (CMS), and the completed Skilled Nursing Facility Advanced Beneficiary Notice of Non Coverage Form (SNF ABN) 10055.

Inspectors wroteThe facility had a census of 96 residents. The sample included 21 residents with one resident reviewed for discharge. Based on record review and interview, the facility failed to develop a discharge summary that included a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay and post discharge plan for Resident (R) 98.

Inspectors wroteThe facility had a census of 96 residents. The sample included 21 residents with ten reviewed for Activities of Daily Living (ADLs). Based on observation, record review, and interview, the facility failed to provide bathing services as care planned for three of the eight sampled residents, Resident (R23), R70, and R57.

Inspectors wroteThe facility had a census of 96 residents. The sample included 21 residents. Based on observation, record review, and interview the facility failed to provide a physician ordered external urinary catheter for one sampled resident, Resident, (R)23.

Inspectors wroteThe facility had a census of 96 residents. The sample included 21 residents with two sampled for behavioral/emotional status. Based on observation, interview, and record review the facility failed to monitor and place interventions for two residents, Resident (R) 97 and R87 with a known history for sexual/intimate behaviors/activity.

Inspectors wroteThe facility had a census of 96 residents. The sample included 21 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to provide the physician ordered medications for one of six sampled residents, Resident (R) 70.

Inspectors wroteThe facility had a census of 96 residents. The sample included 21 residents with six reviewed for unnecessary medications. Based on observations, record review, and interview, the facility's Consultant Pharmacist failed to follow up with the physician and Director of Nursing on recommendations to establish individualized physician ordered blood sugar parameters for Resident (R) 22 and an inappropriate diagnosis for antipsychotic (a class of medications used to manage delusions, hallucinations, and paranoia) medication administration for R12.

Inspectors wroteThe facility had a census of 96 residents. The sample included 21 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to adequately monitor low blood sugars and notify the physician to ensure appropriate care and treatment for one of six sampled residents Resident (R) 22.

Inspectors wroteThe facility had a census of 96 residents. The sample included 21 residents with six reviewed for unnecessary medications. Based on observations, record review, and interview, the facility failed to ensure an appropriate diagnosis for Resident (R) 12's olanzapine (Zyprexa), an antipsychotic (a class of medications used to manage delusions, hallucinations, and paranoia) .

Inspectors wroteThe facility had a census of 96 residents. Based on observation, record review, and interview the facility failed to provide a certified dietary manager to carry out the functions of food and nutritional services for the 93 residents who resided in the facility and received meals from the facility kitchen.