Swan Health at Overland Park

Inspectors wroteBased on record review and interviews, the facility failed to ensure staff provided the necessary assistance with activities of daily living for Resident (R) 1 when staff failed to wash his face, provide baths, and trim his nails.

Inspectors wroteBased on record review and interviews, the facility failed to provide adequate care and services related to skin issues when staff failed to address and treat Resident (R) 1's seborrheic dermatitis (a common, chronic inflammatory skin condition causing oily patches, stubborn dandruff, and yellow or white scales) on his face and scalp.

Inspectors wroteBased on record review and interviews, the facility failed to provide foot care to Resident (R) 1, who was dependent on staff for foot care and whose toenails were long.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to provide the necessary care and services related to indwelling catheter care for Resident (R) 1 when staff removed the catheter, failed to reinsert a catheter and monitor to ensure adequate urine output. Additionally, staff failed to obtain physician involvement. R1 subsequently developed a change in condition and was diagnosed with urine retention, urinary tract infection, and acute kidney injury.

Inspectors wroteThe facility identified a census of 37 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to implement interventions to prevent further weight loss for Resident (R) 1. R1 was admitted to the facility on [DATE] and had a weight loss of 3.85% by 07/02/25 with no documented intervention or response to the loss. R1's weight further declined to a significant loss of 8.85% by 08/01/25 (more than 7.5% in three months) with no documented intervention or response from the facility until 08/14/25. This deficient practice resulted in a total significant weight loss of -11.15% for R1 from 06/06/25 to 08/20/25.

Inspectors wroteThe facility identified a census of 32 residents. Based on observation, record review, and interview, the facility failed to provide consistent Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week. This placed all the residents who resided in the facility at risk of a lack of assessment and inappropriate care.

Inspectors wroteThe facility identified a census of 32 residents. The sample included 12 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 affected all 32 residents residing in the facility. Findings Included: - On 05/05/25, Administrative Staff A provided a Facility Assessment updated 03/01/25. A review of the assessment revealed the following: The assessment identified the required staffing needs per day but failed to identify the specific staffing needs for days, nights, and weekend shifts. On 05/05/25, a review of the facility's Payroll Based Journaling (PBJ - Staffing Data Report) from 04/01/24 to 03/31/25 revealed excessively low weekend staffing triggered in all four quarters. [...]

Inspectors wroteThe facility reported a census of 32 residents. The sample included 12 residents. Based on record review and interviews, the facility failed to submit accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ - Staffing Data Report), when the facility failed to submit accurate weekend staffing coverage hours. This placed the residents at risk for unidentified and ongoing inadequate staffing.

Inspectors wroteThe facility identified a census of 32 residents. The sample included 12 residents. Based on record review and interviews, the facility failed to develop and implement the core elements of antibiotic stewardship to ensure an effective infection prevention and control program, including antibiotic stewardship for residents in the facility.

Inspectors wroteThe facility reported a census of 32 residents. Based on observations, record review, and interviews, the facility failed to ensure safe medication storage with three of the five medication carts. This deficient practice placed the residents at risk for diversion and ineffective medication regimen. Findings Included: - On 05/04/25 at 10:00 AM, an inspection of the facility revealed three unlocked and unsupervised medication carts on the facility's 200 hallway. An inspection of the medication carts revealed resident medications, stock medications, and medicated ointments stored in the carts. On 05/04/25 at 10:06 AM, Licensed Nurse (LN) G stated she was away from the medication cart for only five minutes, but stated she should have locked them before leaving them. She secured the medication carts. [...]

Inspectors wroteThe facility identified a census of 32 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observations, record review, and interviews, the facility failed to ensure Residents (R) 19 and R8 remained free from unnecessary psychotropic (alters mood or thought) medications and chemical restraint (use of medication to control behaviors). This deficient practice placed both residents at risk for sedation and chemical restraint. Findings Included: [...]

Inspectors wroteThe facility identified a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to complete the Care Area Assessment (CAA) analysis of findings, related to a Comprehensive Minimum Data Set (MDS), for two residents, Residents (R) 12 and R20, in order to address the underlying cause, risk factors, and other contributing factors to ensure the resident received care based on their individual needs. This placed these residents at risk for impaired care and decreased quality of life due to unidentified care needs.

Inspectors wroteThe facility identified a census of 32 residents. The sample included 12 residents, with five sampled residents reviewed for unnecessary medications. Based on observations, record review, and interviews, the facility failed to ensure the Consultant Pharmacist's (CP) recommended a Centers for Medicare and Medicaid (CMS) approved indication related to Resident (R) 19's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication. This deficient practice placed R19 at risk of unnecessary medication administration and related complications. Findings Included: [...]

Inspectors wroteThe facility identified a census of 32 residents. The sample included 12 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the physician was notified of blood sugars outside the physician ordered parameters for Resident (R) 12 and the facility failed to ensure antihypertensive (medication used to treat high blood pressure) medication was administered per the physician ordered parameters for R16. These deficient practices placed these residents at risk for unnecessary medication administration and possible adverse reactions.

Inspectors wroteThe facility identified a census of 32 residents, with one resident on puree textured diets. Based on observations, interviews, and record review, the facility failed to follow nutritionally approved recipes during the preparation of the facility's puree-based meals. This deficient practice placed one resident at risk for complications related to nutritional impairment.

Inspectors wroteThe facility identified a census of 32 residents. The sample included 12 residents. Based on record review and interview, the facility failed to update its daily posted staffing form to provide accurate daily staffing information.

Inspectors wroteThe facility identified a census of 29 residents. The sample included three residents reviewed for feeding tubes. Based on record review and interviews, the facility failed to prevent the neglect of Resident (R) 1 when staff did not provide adequate monitoring and timely care and attention to R1's percutaneous endoscopic gastrostomy (PEG tube- feeding tube through the abdominal wall directly into the stomach) site, which became infected, her abdomen became swollen and inflamed, and her right lower abdomen developed darkening, which staff documented as bruising. On 02/18/25 at 05:34 AM, R1 had a swollen abdomen and a large palpable mass around the PEG tube, with pus noted coming from the site. [...]

Inspectors wroteThe facility identified a census of 29 residents and 11 residents with trust accounts. The sample included three residents who were reviewed for misappropriation. Based on observation, record review, and interviews, the facility failed to ensure residents with trust accounts managed by the facility remained free from misappropriation when Administrative Staff B misappropriated funds from the resident trust fund account. This deficient practice placed all residents with trust accounts managed by the facility at risk for misappropriation, financial instability, and impaired rights.

Inspectors wroteThe facility identified a census of 29 residents. Based on record review and interviews, the facility failed to notify Resident (R) 1's representative of the plan of care changes. This deficient practice had the risk of miscommunication between R1, their representative, and the facility.

Inspectors wroteThe facility identified a census of 29 residents and 11 residents with trust accounts. The sample included three residents who were reviewed for misappropriation. Based on observation, record review, and interviews, the facility failed to report the suspicion of misappropriation of resident funds to the State Agency (SA) and law enforcement within the required timeframe. This deficient practice placed all residents with trust accounts managed by the facility at risk for unidentified and ongoing misappropriation.

Inspectors wroteThe facility identified a census of 27 residents. The sample included 12 residents with one resident reviewed for accidents. Based on observation, record review, and interviews, the facility failed to routinely reassess the continued use of upper half siderails to assure safety for Resident (R) 13. This placed the resident at risk for injury related to incorrect or unsafe use of side rails.

Inspectors wroteThe facility identified a census of 27 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure staff possessed the appropriate competencies to safely administer medications per the standards of practice when licensed nursing staff failed to clarify Resident (R) 19's antihypertensive (class of medication used to treat high blood pressure) medication order. This deficient practice placed R19 at risk for medication errors.

Inspectors wroteThe facility identified a census of 27 residents. The sample included 12 residents with five residents reviewed unnecessary medications. Based on observation, record review, and interviews, the facility failed to acknowledge and follow the Consultant Pharmacist's (CP) recommendations to complete a gradual dose reduction (GDR) or provide an indicated rationale for Resident (R)17's psychotropic (a class of medications which affect mood or thoughts) medications. This deficient practice placed R17 at risk for ineffective treatment and unnecessary side effects. Findings Included: [...]

Inspectors wroteThe facility identified a census of 27 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 19's medications had an indication for administration. This deficient practice placed R19 at risk for unnecessary medication use and unwarranted side effects.

Inspectors wroteThe facility identified a census of 27 residents. The sample included 12 residents with five residents reviewed unnecessary medications. Based on observation, record review, and interviews, the facility failed to complete a gradual dose reduction (GDR) or provide a rationale for contraindication related to Resident (R)17 and R19's psychotropic (a class of medications which affect mood or thoughts) medications. The facility additionally failed to provide anindication for use on R19's Haldol (antipsychotic medication- used to treat major mental conditions which cause a break from reality) medication and Lexapro (depression medication). This deficient practice placed both at risk for ineffective treatment and unnecessary side effects. Findings Included: [...]

Inspectors wroteThe facility identified a census of 27 residents. The sample included 12 residents with five reviewed for influenza (highly contagious viral infection) and pneumococcal (type of bacterial infection) immunizations. Based on record review and interviews, the facility failed to provide pneumococcal vaccinations or informed refusals for Residents (R)19. This deficient practice placed R19 at risk for complication related to pneumonia.

Inspectors wroteThe facility identified a census of 27 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to post the previous state inspection information in a location accessible to residents and visitors.

Inspectors wroteThe facility identified a census of 23 residents. Based on observations, record reviews, and interviews, the facility failed to ensure proper personal protective equipment (PPE- gloves, gowns, face shields and/or eye glasses/goggles) usage and failed to ensure adequate hand hygiene was performed. This deficient practice had the risk to spread illness and infection to all residents.

Inspectors wroteThe facility identified a census of 23 residents. The sample included 12 residents with three residents sampled for beneficiary notification. Based on record review and interviews, the facility failed to provide notices for Medicare Non-Coverage to resident and/or resident's family/Durable Power of Attorney (DPOA- document that designated a person who made health care decisions for resident if they were no longer able to make their own decisions) for Resident (R) 3, R124, and R125. This deficient practice had the risk for miscommunication between resident/resident family and facility and potential for missed skilled services and unanticipated charges.

Inspectors wroteThe facility identified a census of 23 residents. The sample included 12 residents; one resident reviewed for hospitalization. Based on observations, record reviews, and interviews, the facility to notify the state ombudsman of transfers and failed to provide a written notification of transfers to Resident (R) 13's family/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 services.

Inspectors wroteThe facility identified a census of 23 residents. The sample included 12 residents; two residents sampled for accidents. Based on observations, record reviews, and interviews, the facility failed to revise the care plan with interventions to prevent further falls for Resident (R) 5. This deficient practice had the risk for further falls, possible injuries from falls, and unwarranted physical complications.

Inspectors wroteThe facility identified a census of 23 residents. The sample included 12 residents; two residents sampled for accidents. Based on observations, record reviews, and interviews, the facility failed to implement and follow-through with interventions after falls to prevent further falls for Resident (R) 5. This deficient practice had the risk for further falls, possible injuries from falls, and unwarranted physical complications.

Inspectors wroteThe facility reported a census of 23 residents. The sample included 12 residents; five residents sampled for unnecessary medication review. Based on observations, record reviews, and interviews, the facility failed to ensure consistent medication administration for Resident (R) 5, failed to ensure ordered medications had diagnoses for R5, and failed to ensure nursing staff notified the physician when blood glucose levels were outside of ordered parameters for R8. This deficient practice had the risk for unwarranted physical complications and unnecessary medication use.

Inspectors wroteThe facility identified a census of 23 residents. The facility had one main kitchen. Based on observation, record review and interview, the facility failed to store food (opened food items in dry storage and the walk-in freezer that were not in a sealed package the was labeled or dated), and failed to properly wash and sanitize food equipment before use. This deficient practice left residents at risk for food borne illness and contamination.