Inspection Reports for Ahc of Overland Park LLC
4700 INDIAN CREEK PARKWAY, OVERLAND PARK, KS, 66207-4068
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 30, 2024, found no deficiencies, confirming the facility corrected all prior issues by October 18, 2024. Earlier inspections showed multiple deficiencies related mainly to resident care practices such as call light accessibility, bathing consistency, catheter and infection control, food safety, and employee background checks. Complaint investigations included a substantiated immediate jeopardy incident in December 2023 involving a resident’s facial burns from smoking while on oxygen, as well as a substantiated case of resident property misappropriation in January 2024. Most complaints from prior years were unsubstantiated, and enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s recent clean inspection suggests improvement following a period of mixed findings and corrective efforts.
Deficiencies (last 11 years)
Deficiencies (over 11 years)
10.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
80% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
35 residents
Based on a September 2024 inspection.
Occupancy over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 30, 2024
Visit Reason
An offsite revisit survey was conducted on 10/30/24 for all previous deficiencies cited on 09/25/24 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 10/18/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 9
Date: Sep 25, 2024
Visit Reason
The inspection was conducted as a health resurvey and complaint investigation at Advanced Health Care of Overland Park.
Complaint Details
The inspection included a complaint investigation identified as KS00190801.
Findings
The facility was found deficient in multiple areas including failure to ensure residents had call lights within reach, failure to provide required Medicaid/Medicare notices, inadequate background checks for employees, inconsistent bathing care, unsafe environment due to unsecured hazardous chemicals, improper Foley catheter care, serving meals at unsafe temperatures, unsanitary food storage practices, and failure to maintain sanitary infection control standards related to medical drains and catheters.
Deficiencies (9)
Failure to ensure Resident 75 had her call light to communicate her needs or call for help.
Failure to provide Resident 82 with a Centers for Medicare and Medicaid Services Notice of Medicare Non-Coverage upon discharge.
Failure to develop and implement a policy prohibiting employment of staff with criminal backgrounds; missing background check for Licensed Nurse H.
Failure to provide consistent bathing opportunities for Resident 18.
Failure to ensure a safe environment free from hazardous chemicals and materials for cognitively impaired independently mobile residents.
Failure to ensure appropriate Foley catheter care for Resident 16; urine collection bag was not maintained below bladder level.
Failure to ensure meals were served at a palatable, safe, and appetizing temperature for Residents 75 and 76.
Failure to maintain sanitary dietary standards related to food storage; multiple food items unlabeled and undated.
Failure to follow sanitary infection control standards related to maintaining biliary drains and Foley catheters; drainage bags resting on floor.
Report Facts
Census: 35
BIMS score: 11
BIMS score: 15
BIMS score: 15
BIMS score: 14
Weight: 250
Food temperature: 90
Food temperature: 98
Food temperature: 94
Food temperature: 92
Food temperature: 95
Food temperature: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse H | Licensed Nurse | Named in finding for missing criminal background check. |
| Certified Nurse's Aid M | Certified Nurse's Aide | Mentioned in relation to call light placement, catheter care, bathing schedule, and treatment cart security. |
| Licensed Nurse G | Licensed Nurse | Mentioned in relation to call light placement, catheter care, and wound cart security. |
| Administrative Nurse D | Administrative Nurse | Mentioned in relation to call light policy, NOMNC documentation, bathing documentation, and catheter care. |
| Administrative Staff A | Administrative Staff | Mentioned in relation to missing background check and wound cart security. |
| Consultant GG | Consultant | Mentioned in relation to resident condition upon hospital transfer. |
| Dietary Staff BB | Dietary Staff | Mentioned in relation to food temperature concerns and food storage labeling. |
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Sep 25, 2024
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during the Advanced Health Care OP RS inspection conducted on 09/25/2024.
Findings
The plan addresses multiple deficiencies including call light accessibility, discharge notification, criminal background checks, bathing documentation, treatment cart security, catheter care, meal service temperature, food labeling, and infection control related to medical devices. Corrective actions include staff education, audits, and systemic changes to ensure compliance.
Deficiencies (9)
Call light placement and accessibility
Discharge notification to Medicare A patients
Lack of evidence of criminal background check on file
Bathing frequency and documentation
Treatment cart security and chemical storage
Catheter placement and drainage maintenance
Meal service temperature and delivery process
Food labeling and dating
Infection control standards for medical drains and catheters
Report Facts
Audit frequency: 4
Audit frequency: 2
Plan of Correction completion date: 2024
Inspection Report
Routine
Census: 35
Deficiencies: 9
Date: Sep 25, 2024
Visit Reason
The inspection was a routine survey of Advanced Health Care of Overland Park to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure residents had call lights within reach, failure to provide Medicare non-coverage notices upon discharge, inadequate background checks for employees, inconsistent bathing assistance, unsafe storage of hazardous chemicals, improper Foley catheter care, serving meals at unsafe temperatures, unsanitary food storage practices, and failure to maintain infection control standards related to medical drains and catheters.
Deficiencies (9)
Failed to ensure Resident 75 had her call light to communicate her needs or call for help.
Failed to provide Resident 82 with a Notice of Medicare Non-Coverage upon discharge from Medicare A services.
Failed to develop and implement a policy prohibiting employment of staff without completed criminal background checks.
Failed to provide consistent bathing opportunities for Resident 18.
Failed to ensure a safe environment free from hazardous chemicals and materials for cognitively impaired residents.
Failed to ensure appropriate Foley catheter care for Resident 16 by not maintaining urine collection bag below bladder level.
Failed to ensure meals were served at a palatable, safe, and appetizing temperature for Residents 75 and 76.
Failed to maintain sanitary dietary standards related to food storage, including unlabeled and undated opened food containers.
Failed to follow sanitary infection control standards related to maintaining biliary drains and Foley catheters.
Report Facts
Residents Affected: 35
Sample size: 12
Bathing missed dates: 4
Food temperature: 90
Food temperature: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Stated call lights should be clipped or on bed within reach; stated catheter bags should be checked and positioned properly |
| Administrative Nurse D | Administrative Nurse | Stated staff were to ensure call lights remained within reach and catheter bags positioned properly |
| Certified Nurse's Aid M | Certified Nurse's Aide | Observed call light out of reach; stated catheter bags and medical drains should be positioned below bladder level and never touch floor |
| Administrative Staff A | Administrative Staff | Unable to find criminal background check for Licensed Nurse H; stated background checks should be completed for all employees |
| Dietary Staff BB | Dietary Staff | Stated food packaging needed to be labeled and dated; identified concerns with meal service temperature |
| Consultant GG | Consultant | Observed resident with pressure injury and poor hygiene upon hospital admission |
Inspection Report
Routine
Census: 35
Deficiencies: 9
Date: Sep 25, 2024
Visit Reason
The inspection was a routine survey of Advanced Health Care of Overland Park to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure residents had call lights within reach, failure to provide Medicare non-coverage notices, inadequate background checks for employees, inconsistent bathing assistance, unsafe storage of hazardous chemicals, improper Foley catheter care, serving meals at unsafe temperatures, unsanitary food storage practices, and failure to maintain infection control standards related to medical drains and catheters.
Deficiencies (9)
Failed to ensure Resident 75 had her call light to communicate her needs or call for help.
Failed to provide Resident 82 with a Notice of Medicare Non-Coverage upon discharge from Medicare A services.
Failed to develop and implement a policy prohibiting employment of staff without completed criminal background checks.
Failed to provide consistent bathing opportunities for Resident 18.
Failed to ensure a safe environment free from hazardous chemicals and materials for cognitively impaired residents.
Failed to ensure appropriate Foley catheter care for Resident 16 by not maintaining urine collection bag below bladder level.
Failed to ensure meals were served at a palatable, safe, and appetizing temperature for Residents 75 and 76.
Failed to maintain sanitary dietary standards related to food storage; multiple food items were unlabeled and undated.
Failed to follow sanitary infection control standards related to maintaining biliary drains and Foley catheters.
Report Facts
Residents in census: 35
Residents in sample: 12
Bathing missed dates: 4
Temperature of scrambled eggs: 90
Temperature of oatmeal: 98
Temperature of cherry crumble: 94
Temperature of scrambled eggs: 92
Temperature of oatmeal: 95
Temperature of cherry crumble: 90
Resident weight: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Stated call lights should be clipped or within reach and catheter bags should be positioned properly |
| Administrative Nurse D | Administrative Nurse | Stated staff were to ensure call lights remained within reach and catheter bags were checked each interaction |
| Certified Nurse's Aid M | Certified Nurse's Aid | Observed call light placement, catheter bag positioning, and bathing documentation |
| Administrative Staff A | Administrative Staff | Reported missing background check for Licensed Nurse H and secured treatment carts |
| Dietary Staff BB | Dietary Staff | Reported concerns with food temperature and food packaging labeling |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 26, 2024
Visit Reason
A revisit survey was conducted on 02/26/24 to verify correction of all previous deficiencies cited on 01/31/24.
Findings
All deficiencies cited in the prior inspection have been corrected as of 02/26/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 31, 2024
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection related to patient misappropriation and security of personal belongings.
Findings
The facility identified that a resident had been discharged and that all patients were at risk of misappropriation. Patients were interviewed about stolen items and offered lock boxes to secure valuables. Staff received training on protecting residents from misappropriation, and audits of new admissions regarding lock box offerings were implemented.
Deficiencies (1)
Failure to protect residents from misappropriation and secure their valuables.
Report Facts
Date of Compliance: Feb 13, 2024
QAPI meeting date: Jan 31, 2024
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 1
Date: Jan 31, 2024
Visit Reason
The inspection was conducted as a complaint investigation (#KS00185283) regarding misappropriation of resident property at the facility.
Complaint Details
The complaint investigation found that Resident 1 had multiple checks missing from his checkbook, with one check cashed fraudulently for approximately $1,200 and another attempt caught by the bank. The facility was unable to identify the perpetrator despite interviews and police involvement.
Findings
The facility failed to ensure Resident 1 remained free from misappropriation of property when his checks were stolen from his room and cashed for approximately $1,200. This caused Resident 1 to feel anger and frustration and placed him at risk for further misappropriation and decline in psychosocial well-being.
Deficiencies (1)
Facility failed to ensure Resident 1 remained free from misappropriation of property when his checks were stolen and cashed.
Report Facts
Census: 37
Checks missing: 8
Fraudulent check amount: 1200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Administrative Staff | Interviewed Resident 1 and reported stolen checks to police; involved in investigation |
| Administrative Nurse D | Administrative Nurse | Provided statements regarding inventory logs and security boxes |
| Certified Nurse Aide M | Certified Nurse Aide | Described admission process and handling of resident valuables |
| Certified Nurse Aide N | Certified Nurse Aide | Described checklist for resident valuables and lock box availability |
| Certified Nurse Aide O | Certified Nurse Aide | Observed Resident 1's checkbook and advised on storage |
| Administrative Nurse E | Administrative Nurse | Described facility's handling of valuables and inventory process |
| Licensed Nurse G | Licensed Nurse | Described admission process and referral for lockbox |
| Licensed Nurse H | Licensed Nurse | Described resident inventory printout and valuables handling |
| Administrative Nurse F | Administrative Nurse | Described admission procedures and lockbox availability |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Date: Dec 13, 2023
Visit Reason
The inspection was conducted due to a complaint or incident involving a resident (R1) who suffered facial burns after smoking while on oxygen, raising concerns about the facility's supervision and hazard identification related to smoking safety.
Complaint Details
The complaint investigation found that R1 was allowed to smoke while on oxygen, which ignited the nasal cannula causing facial burns and hypoxia requiring emergency treatment and hospital admission to a burn unit. Staff failed to assess R1's smoking status and did not provide adequate supervision during smoking breaks. The facility's smoking policy was outdated and lacked proper safety assessments.
Findings
The facility failed to identify hazards and provide adequate supervision to ensure safe smoking for R1, who was allowed to smoke while receiving oxygen via nasal cannula, resulting in ignition of the cannula and facial burns. The facility's smoking policy lacked proper assessment and supervision protocols, and staff failed to assess R1's smoking status accurately. Corrective actions included updating the smoking policy, staff training, and safety assessments for smoking residents.
Deficiencies (1)
Failure to identify hazards and provide adequate supervision to prevent accidents related to smoking while on oxygen, resulting in immediate jeopardy to resident health and safety.
Report Facts
Census: 38
Oxygen flow rate: 6
Oxygen flow rate with activity: 8
Date of incident: Dec 8, 2023
Date survey completed: Dec 13, 2023
Number of smoking residents assessed: 2
Date corrective actions completed: Dec 11, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Took R1 outside for smoking break and left R1 unattended with oxygen on |
| LN H | Licensed Nurse | Observed R1's nasal cannula on fire, disconnected oxygen, and provided initial care |
| LN G | Licensed Nurse | Notified and assisted in care after R1's injury |
| LN I | Licensed Nurse | Did not ask R1 about smoking status and reviewed hospital paperwork |
| Administrative Nurse D | Administrative Nurse | Stated expectation for staff to assess smoking status and safety on admission |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Date: Dec 13, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to an immediate jeopardy incident involving Resident 1 (R1) who sustained facial burns after his oxygen nasal cannula ignited while smoking.
Complaint Details
The complaint investigation #KS00184548 and KS00184552 found immediate jeopardy due to Resident 1's oxygen nasal cannula igniting while smoking, causing facial burns and hypoxia requiring emergent treatment and hospital admission to a burn unit.
Findings
The facility failed to identify hazards and provide adequate supervision to ensure safe smoking for R1, who was admitted with oxygen dependency and suffered burns due to smoking with oxygen on. The facility's smoking policy was outdated and staff failed to assess R1's smoking status and safety needs. Corrective actions including policy updates and staff training were completed prior to the survey.
Deficiencies (1)
Failure to identify hazards and provide adequate supervision and care to ensure safe smoking for Resident 1, resulting in facial burns and immediate jeopardy.
Report Facts
Census: 38
Oxygen flow rate: 6
Incident time: 1734
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse H | Licensed Nurse | Observed Resident 1 trying to put out the fire and disconnected oxygen tubing |
| Certified Nurse Aide M | Certified Nurse Aide | Took Resident 1 outside for a cigarette break and left him unattended with oxygen on |
| Licensed Nurse G | Licensed Nurse | Notified and responded to Resident 1's incident, cleaned soot, and took over care |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 11, 2023
Visit Reason
The document addresses findings from complaint investigations #KS00184548 and KS00184552 related to an immediate jeopardy incident involving Resident 1 (R1) who sustained facial burns due to a smoking-related accident while on oxygen.
Complaint Details
The visit was complaint-related, involving immediate jeopardy for Resident 1 due to a smoking-related incident where the resident's nasal cannula ignited while smoking with oxygen in use. The failure was substantiated and placed the resident in immediate jeopardy.
Findings
The facility failed to ensure staff identified smoking-related hazards and provided adequate supervision to prevent smoking-related accidents, resulting in R1's nasal cannula igniting and causing facial burns and hypoxia. Corrective actions included updating the smoking policy, conducting safety assessments for smoking residents, and staff training on smoking safety.
Deficiencies (1)
Failure to ensure staff identified smoking related hazards and provided adequate care and supervision to avoid preventable smoking related accidents for admitting resident R1.
Report Facts
Oxygen flow rate: 6
Dates of corrective actions: Dec 11, 2023
Date of smoking safety assessment: Dec 9, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| FELICIAMAJEWSKI | RN | Submitted the Plan of Correction to KDADS |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| CNA M | Certified Nurse Aide | Took Resident 1 outside for a cigarette break during which the incident occurred |
| LN H | Licensed Nurse | Observed Resident 1 trying to put out the fire and turned off oxygen flow |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 14, 2023
Visit Reason
An offsite revisit survey was conducted on 04/14/23 for all previous deficiencies cited on 02/28/23 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of 04/12/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Routine
Census: 30
Deficiencies: 4
Date: Feb 28, 2023
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with care plan development, activities of daily living assistance, accident hazard prevention, and food safety standards at the nursing home.
Findings
The facility failed to revise care plans for residents after falls, provide consistent bathing assistance, secure hazardous chemicals, and properly test and document dishwashing sanitization chemicals and ice machine safety. These deficiencies placed residents at risk for uncommunicated care needs, impaired skin integrity, accidents, and foodborne illness.
Deficiencies (4)
Failed to revise Residents 15 and 33's care plans to reflect interventions implemented for recent falls.
Failed to provide consistent bathing opportunities and required assistance for Resident 15.
Failed to secure chemicals in a safe, locked area, and out of reach of cognitively impaired independently mobile residents.
Failed to ensure staff properly tested dishwashing sanitization chemicals and recorded dish machine temperatures; ice machine lid left open.
Report Facts
Census: 30
Bathing occurrences: 6
Dish machine temperature undocumented opportunities: 17
Dish machine chemical test undocumented days: 16
Chemical wipe containers unsecured: 12
Residents affected by unsecured chemicals: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurses Aid M | Certified Nurses Aid | Provided statements regarding fall risk, bathing schedules, chemical safety, and ice machine maintenance |
| Licensed Nurse G | Licensed Nurse | Provided statements regarding fall risk interventions, bathing documentation, and chemical safety |
| Administrative Nurse D | Administrative Nurse | Provided statements regarding care plan revisions, bathing documentation, chemical safety education |
| Dietary Staff DD | Dietary Staff | Reported change in sanitization chemical company and issues with chemical test strips |
| Dietary Staff BB | Dietary Staff | Reported notification to chemical provider about sanitization chemical issues |
| Dietary Staff CC | Dietary Staff | Reported chemical test strips used were for fruits and vegetables, not dish machines |
| Licensed Nurse H | Licensed Nurse | Stated responsibility for cleaning ice machine and importance of closing ice machine lid |
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 4
Date: Feb 28, 2023
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #KS00177109 to evaluate compliance with care plan revisions and other regulatory requirements.
Complaint Details
The visit was triggered by a complaint investigation #KS00177109.
Findings
The facility failed to revise care plans for residents with recent falls, failed to provide consistent bathing and required assistance, failed to secure chemicals safely, and failed to properly test dishwashing sanitization chemicals and maintain food safety standards. These deficiencies placed residents at risk for uncommunicated care needs, impaired skin integrity, accidents, and foodborne illness.
Deficiencies (4)
Failed to revise care plans for residents R15 and R33 to reflect interventions implemented for recent falls.
Failed to provide consistent bathing opportunities and required assistance for Resident R15.
Failed to secure chemicals in a safe, locked area, leaving disinfectant wipes accessible to cognitively impaired residents.
Failed to properly test dishwashing sanitization chemicals and record dish machine temperatures; ice machine lid left open in nourishment area.
Report Facts
Residents in sample: 12
Bathing occurrences: 6
Dish machine temperature undocumented opportunities: 17
Dish machine PPM undocumented days: 16
Chemical wipe containers unsecured: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurses Aid (CNA) M | Provided statements regarding care plan access, fall risk, bathing schedules, chemical wipe safety, and ice machine maintenance. | |
| Licensed Nurse (LN) G | Provided statements regarding fall interventions, care plan revisions, chemical wipe safety, and blood glucose monitoring. | |
| Administrative Nurse D | Provided statements regarding care plan requirements, bathing documentation, chemical wipe safety education. | |
| Dietary Staff DD | Reported issues with new sanitization chemical strips and notified provider. | |
| Dietary Staff BB | Reported change in sanitization chemical company and provider notification. | |
| Dietary Staff CC | Explained chemical test strips were for produce, not dish machines. | |
| Licensed Nurse (LN) H | Responsible for cleaning ice machine and stated responsibility for closing ice machine lid. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 14, 2022
Visit Reason
A revisit survey was conducted on 03/14/22 for all previous deficiencies cited on 02/16/22.
Findings
All deficiencies have been corrected as of the compliance date of 02/26/22, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Feb 16, 2022
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a prior inspection report dated 02/16/2022 for Advanced Healthcare of Overland Park.
Findings
The plan addresses multiple deficiencies related to abuse, neglect, and mistreatment policies and procedures, including staff in-service training, policy updates, and monitoring to ensure proper identification, reporting, and investigation of allegations of abuse.
Deficiencies (4)
Failure to provide appropriate supervision of patients to prevent abuse, neglect, or mistreatment.
Inadequate abuse policy and procedure, including reporting requirements.
Failure to properly identify and report allegations of abuse.
Failure to conduct and document thorough investigations in response to allegations of abuse.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matthew Child | Administrator | Administrator who submitted the Plan of Correction and responsible for monitoring and reporting findings to QAPI committee. |
| Felicia Majewski | Person who added and modified the Plan of Correction. |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 4
Date: Feb 16, 2022
Visit Reason
The inspection was a partial extended survey and complaint investigation triggered by allegations of verbal abuse, neglect, and mistreatment of Resident 1 by staff.
Complaint Details
The complaint investigation was triggered by allegations that on 02/06/22, CNA M verbally abused Resident 1 by calling her a liar, telling her she was 'the devil,' and mocking her cries for help. CNA M also neglected to ensure Resident 1 had her call light within reach. Resident 1's representative recorded the incident and reported it to the facility. The facility failed to recognize and report this as abuse and did not conduct a thorough investigation.
Findings
The facility failed to ensure Resident 1 remained free from verbal abuse, neglect, and mistreatment by staff, specifically by Certified Nurse Aide M. The facility also failed to properly identify the situation as abuse, report it immediately to the appropriate authorities, and conduct a thorough investigation. Resident 1 was verbally abused, neglected by not having the call light within reach, and mistreated, placing her in immediate jeopardy.
Deficiencies (4)
Failure to ensure Resident 1 remained free from verbal abuse, neglect, and mistreatment by staff.
Failure to develop and implement abuse/neglect policies that include required reporting timeframes.
Failure to immediately report alleged violations of abuse to appropriate state agencies.
Failure to conduct and document a thorough investigation in response to an allegation of abuse.
Report Facts
Census: 36
Resident Admission Date: Jan 28, 2022
Resident Discharge Date: Feb 11, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide M | Certified Nurse Aide | Named in verbal abuse and neglect findings related to Resident 1 |
| Licensed Nurse H | Licensed Nurse | Documented rounds and reported Resident 1's condition and allegations |
| Licensed Nurse G | Licensed Nurse | Spoke with Resident 1's representative and reported incident |
| Administrative Staff A | Administrator | Notified of incident, failed to report as abuse, placed CNA M on do not return list |
| Administrative Nurse D | Administrative Nurse | Notified of incident, involved in investigation and reporting |
| Certified Nurse Aide N | Certified Nurse Aide | Witnessed incident and provided statement |
| Licensed Nurse M | Licensed Nurse | Instructed staff to report incident and documented Resident 1's condition |
| Licensed Nurse N | Licensed Nurse | Involved in incident response and reporting |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 21, 2021
Visit Reason
An offsite revisit survey was conducted on 10/21/21 to verify correction of all previous deficiencies cited on 09/01/21.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date of 09/24/21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Sep 24, 2021
Visit Reason
This document is a Plan of Correction submitted by Advanced Health Care of Overland Park in response to deficiencies cited in a prior inspection report dated 9/1/2021.
Findings
The Plan of Correction outlines immediate responses, ongoing monitoring, and quality assurance actions taken to address multiple deficiencies including resident discharge notifications, fall interventions, medication monitoring, documentation practices, and infection control.
Deficiencies (6)
Failure to notify Ombudsman and family upon resident transfer to acute care.
Inadequate interventions and documentation related to resident falls.
Inadequate documentation of bowel movements and weight monitoring per physician orders.
Failure to ensure PRN psychotropic medications have appropriate stop dates or physician evaluations.
Expired or unlabeled medications present in storage areas.
Inadequate hand hygiene practices among staff.
Report Facts
Discharge dates: 3
Audit frequency: 4
Patient rooms per audit: 4
CNAs audited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matthew Child | Administrator | Submitted the Plan of Correction to KDADS. |
| Shirley Boltz | Contact person for Plan of Correction assistance. |
Inspection Report
Routine
Census: 37
Deficiencies: 7
Date: Sep 1, 2021
Visit Reason
Routine inspection of Advanced Health Care of Overland Park nursing home to assess compliance with regulatory requirements including resident care, medication management, safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to provide timely written notification of resident transfers, inadequate fall prevention investigations and interventions, failure to ensure consistent medication regimen reviews and monitoring, failure to discard expired medications and properly store medications, failure to ensure psychotropic medication orders had required stop dates, and failure to perform proper hand hygiene during dressing changes.
Deficiencies (7)
Failed to provide timely written notification of resident transfers to resident or family.
Failed to investigate causative factors and ensure interventions were followed for fall prevention.
Failed to ensure licensed pharmacist performed monthly drug regimen review and reported irregularities.
Failed to ensure Consultant Pharmacist identified and reported lack of consistent daily weights, bowel monitoring, and blood glucose monitoring.
Failed to ensure psychotropic medication PRN order had required stop date and physician evaluation.
Failed to discard expired medications and influenza vaccinations; failed to properly store and date Tubersol vials, insulin pens, eye drops, and inhaler.
Failed to perform hand hygiene after doffing and before donning gloves during dressing changes.
Report Facts
Residents sampled: 13
Residents affected: 37
Medication doses: 12
Weight increase: 4.5
Expired medications: 2
Expired influenza vaccinations: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Provided multiple statements regarding transfer notifications, fall prevention, medication administration, and hand hygiene practices. |
| Licensed Nurse G | Licensed Nurse | Provided statements regarding transfer notifications, fall investigations, and hand hygiene. |
| Certified Nurse Aide M | Certified Nurse Aide | Provided statements regarding fall response, visual checks, weight monitoring, and hand hygiene. |
| Consultant Pharmacist GG | Consultant Pharmacist | Performed monthly medication reviews and identified irregularities in medication monitoring. |
| Licensed Nurse H | Licensed Nurse | Provided statements regarding weight and blood glucose monitoring procedures. |
| Licensed Nurse I | Licensed Nurse | Provided statements regarding medication storage and labeling. |
| Administrative Nurse E | Administrative Nurse | Observed performing dressing changes and hand hygiene practices. |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 6
Date: Sep 1, 2021
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #KS00165079 to evaluate compliance with regulatory requirements.
Complaint Details
The inspection was triggered by a complaint investigation #KS00165079.
Findings
The facility was found deficient in multiple areas including failure to provide written transfer notifications, inadequate fall prevention and investigation, failure to ensure proper drug regimen review and monitoring, use of unnecessary psychotropic medications without proper evaluation, improper medication storage and labeling, and failure to perform proper hand hygiene during dressing changes.
Deficiencies (6)
Failure to provide written notification of transfer to resident or family as soon as practicable.
Failure to investigate causative factors and ensure interventions were followed for fall prevention.
Failure to ensure the Consultant Pharmacist identified and reported irregularities in drug regimen review including bowel monitoring, weights, and blood sugar monitoring.
Failure to ensure resident was free from unnecessary psychotropic medications; PRN lorazepam lacked required stop date and physician evaluation.
Failure to label, store, and discard medications and biologicals properly including expired medications, undated opened insulin pens, eye drops, inhalers, and Tubersol vials.
Failure to perform hand hygiene after doffing gloves or before donning gloves during dressing changes.
Report Facts
Residents sampled: 13
PRN lorazepam administrations: 18
Weight increase: 4.5
Expired influenza vaccinations: 7
Tubersol vials undated: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Named in findings related to transfer notification, fall prevention, medication monitoring, and hand hygiene deficiencies. |
| Licensed Nurse G | Licensed Nurse | Named in findings related to fall prevention and hand hygiene deficiencies. |
| Consultant Pharmacist GG | Consultant Pharmacist | Named in findings related to drug regimen review deficiencies. |
| Certified Nurse Aide M | Certified Nurse Aide | Named in findings related to fall prevention and medication monitoring. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 30, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on June 30, 2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 38
Deficiencies: 0
Date: Jun 30, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 3, 2019
Visit Reason
The document is a Plan of Correction submitted in response to a health survey of the facility.
Findings
The health survey resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 3, 2019
Visit Reason
The health survey was conducted as a routine annual inspection to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The survey resulted in no deficiency citations, indicating full compliance with the regulatory requirements at the time of inspection.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 4, 2018
Visit Reason
The document is a Plan of Correction submitted in response to a health survey of the facility.
Findings
The health survey resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Deficiencies (1)
No deficiency citations were found during the health survey.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Oct 4, 2018
Visit Reason
The health survey was conducted as an annual inspection to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The survey resulted in no deficiency citations, indicating full compliance with the regulatory requirements.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Oct 4, 2018
Visit Reason
The health survey was conducted as a routine annual inspection to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B for long term care facilities.
Findings
The survey resulted in a finding of no deficiency citations with respect to applicable regulations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 1, 2018
Visit Reason
A complaint survey was conducted on 02/01/18 for complaint #KS00125984.
Complaint Details
Complaint #KS00125984 was investigated and found to be unsubstantiated.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 1, 2018
Visit Reason
A complaint survey was conducted on 02/01/18 for complaint #KS00125984.
Complaint Details
Complaint #KS00125984 was investigated and found to be unsubstantiated with no noncompliance identified.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 1, 2018
Visit Reason
A complaint survey was conducted on 02/01/18 for complaint #KS00125984.
Complaint Details
Complaint #KS00125984 was investigated and found to be unsubstantiated with no noncompliance identified.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 11, 2017
Visit Reason
The inspection was conducted as a health survey and complaint investigation #KS00113454 for the facility Advanced Health Care of Overland Park.
Complaint Details
Complaint investigation #KS00113454 resulted in no deficiency citations.
Findings
The survey and complaint investigation resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, requirements for long term care facilities.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 11, 2017
Visit Reason
This document is a Plan of Correction submitted by the provider in response to a prior deficiency report.
Findings
No deficiencies were cited in the referenced inspection report dated 05/11/2017.
Deficiencies (1)
No deficiencies cited
Inspection Report
Life Safety
Deficiencies: 1
Date: Sep 7, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be at 'F' level, indicating no harm with potential for more than minimal harm but not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
Deficiencies cited at 'F' level severity
Report Facts
Effective date for denial of payments: Dec 7, 2016
Provider agreement termination date: Mar 7, 2017
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and involved in enforcement |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Plan of Correction
Deficiencies: 13
Date: Oct 23, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified during a prior inspection.
Findings
The plan addresses multiple deficiencies related to honoring patient preferences for wake-up times and activities, skin assessments and bruising, bathing and toileting schedules, medication administration including blood pressure and insulin management, infection control practices, and environmental safety such as call light and exit door systems. Systemic changes include staff in-servicing, monitoring, and audits to ensure compliance and correction of identified issues.
Deficiencies (13)
Concerns regarding honoring preferred wake up times for residents.
Concerns regarding preferred activities for residents.
Concerns regarding activity preferences and bathing preferences.
Concerns related to skin assessments, bruising, and use of skin preventive devices.
Concerns related to bathing preferences and documentation of refusals.
Concerns related to individualized toileting plans and bowel and bladder assessments.
Concerns related to use and reassessment of bed canes, call light system, and accident investigations.
Concerns related to medication management including blood pressure medication parameters, black box warnings, behavior documentation, and bowel movement monitoring.
Concerns related to proper glove use and infection control practices by dietary staff.
Concerns related to insulin administration timing and education.
Concerns related to pharmacy notification and medication issue identification.
Concerns related to housekeeping cleaning practices and disinfectant use.
Concerns related to call light system and exit door sensor functionality and monitoring.
Report Facts
Audit frequency: 25
Call light audit frequency: 3
Number of patient rooms: 38
Gap limit for transfer assistive devices: 4.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Craig Park | Administrator | Administrator who submitted the Plan of Correction. |
| Shirley Boltz | Contact person for Plan of Correction assistance. |
Inspection Report
Follow-Up
Deficiencies: 12
Date: Oct 23, 2015
Visit Reason
This visit was a post-certification revisit to verify that previously identified deficiencies had been corrected.
Findings
All deficiencies previously reported on the CMS-2567 were corrected as of the revisit date of 10/23/2015.
Deficiencies (12)
Deficiency with regulation 483.15(b)
Deficiency with regulation 483.15(f)(1)
Deficiency with regulation 483.20(d), 483.20(k)(1)
Deficiency with regulation 483.25
Deficiency with regulation 483.25(a)(1)
Deficiency with regulation 483.25(d)
Deficiency with regulation 483.25(h)
Deficiency with regulation 483.25(l)
Deficiency with regulation 483.35(i)
Deficiency with regulation 483.60(a),(b)
Deficiency with regulation 483.60(c)
Deficiency with regulation 483.65
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Oct 23, 2015
Visit Reason
This is a revisit report to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that deficiencies identified in prior inspections were corrected as of the revisit date, with specific regulation references noted for the corrections.
Deficiencies (2)
Correction of deficiency related to regulation 26-40-302 (g)(i)(ii)(iii)
Correction of deficiency related to regulation 26-40-302 (2)(a)(i)(ii)(iii)
Report Facts
Deficiencies corrected: 2
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 11
Date: Sep 28, 2015
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation involving multiple complaint investigations (#KS00078397, #KS00082487, and #KS00088192).
Complaint Details
The inspection was triggered by complaint investigations #KS00078397, #KS00082487, and #KS00088192.
Findings
The facility failed to honor resident preferences for wake up times, failed to provide activities meeting resident interests especially on weekends, failed to develop comprehensive care plans addressing resident preferences and needs, failed to provide necessary care for bruising and skin protection, failed to provide adequate bathing, failed to restore bladder function, failed to prevent falls with adequate supervision and safe equipment, failed to monitor and manage unnecessary medications including black box warnings, failed to distribute food under sanitary conditions, failed to provide timely insulin administration, and failed to maintain infection control standards.
Deficiencies (11)
Failed to honor resident preferences for wake up times for 3 sampled residents (#93, #248, #262).
Failed to provide an activity program meeting interests for 2 sampled residents (#4, #248), including lack of weekend and evening activities.
Failed to develop comprehensive care plans addressing individual activity preferences and bathing needs for 3 sampled residents (#4, #248, #263).
Failed to provide necessary care for bruising and skin protection including use of Geri sleeves and heel risers for 3 sampled residents (#254, #259, #262).
Failed to provide adequate bathing for 1 sampled resident (#263).
Failed to restore bladder function and provide adequate toileting assistance for 1 sampled resident (#93).
Failed to provide supervision and safe environment to prevent falls for 3 sampled residents (#93, #248, #255), including unsafe bed canes and lack of call light pager system reliability.
Failed to identify and monitor unnecessary medications including black box warnings for 3 sampled residents (#4, #93, #242), failed to monitor bowel movements and provide treatment for 1 resident (#93), and failed to request physician ordered blood pressure parameters prior to withholding blood pressure medications for 2 residents (#4, #259).
Failed to distribute food under sanitary conditions in the kitchen, including handling bread with soiled gloves.
Failed to provide pharmaceutical services to meet resident needs, including timely insulin administration and monitoring of medications.
Failed to maintain infection control by not following manufacturer recommendations for disinfecting a resident's room on contact isolation precautions.
Report Facts
Resident census: 29
Residents in sample: 19
Bed cane opening size: 11.5
Bed cane opening size: 16
Bed cane opening size: 11.5
Bed cane opening size: 11
Bed cane opening size: 12
Bed cane opening size: 15
Blood pressure: 117
Blood pressure: 67
Blood pressure: 108
Blood pressure: 49
Blood pressure: 109
Blood pressure: 67
Blood pressure: 99
Blood pressure: 62
Bowel movement count: 0
Medication doses held: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Administrative Nursing Staff | Stated facility was moving towards open dining and liberalized medication administration to allow resident preferences for wake up times; also discussed expectations for fall prevention and medication holding |
| Staff H | Licensed Nursing Staff | Provided multiple interviews regarding resident care, medication holding, fall risk, and skin care |
| Staff S | Direct Care Staff | Provided interviews regarding resident care, medication administration, and activity participation |
| Staff Q | Direct Care Staff | Provided interviews regarding resident care, activity participation, and medication administration |
| Staff HH | Therapy Staff / Activity Aide | Provided information about activity scheduling and resident participation |
| Staff Z | Housekeeping Staff | Observed cleaning resident room and interviewed about disinfectant use |
| Staff KK | Pharmacy Consultant | Provided interview about medication reviews and black box warning monitoring |
| Staff O | Direct Care Staff | Observed assisting resident and interviewed about call light pager system |
| Staff V | Direct Care Staff | Interviewed about bathing schedule and resident refusals |
| Staff I | Licensed Nursing Staff | Interviewed about bathing schedule and resident refusals |
| Staff M | Licensed Nursing Staff | Interviewed about resident medications and black box warnings |
| Staff DD | Dietary Staff | Interviewed about meal tray delivery and communication with nursing |
| Staff K | Licensed Nursing Staff | Interviewed about insulin administration timing |
| Staff T | Direct Care Staff | Interviewed about resident behaviors and toileting |
| Staff Y | Direct Care Staff | Interviewed about bathing practices on night shift |
| Staff P | Direct Care Staff | Observed assisting resident with toileting |
| Staff W | Direct Care Staff | Interviewed about resident wake up routines |
| Staff X | Direct Care Staff | Observed assisting resident with dressing |
| Staff GG | Therapy Staff | Interviewed about therapy start times and resident scheduling |
| Staff A | Administrator | Interviewed about activity scheduling and facility policies |
Inspection Report
Enforcement
Deficiencies: 1
Date: Sep 28, 2015
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective October 23, 2015.
Deficiencies (1)
'F' level deficiencies, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the enforcement action. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Jun 10, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but with potential for more than minimal harm, not constituting immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
Most serious deficiencies found were 'F' level, widespread, with no harm but potential for more than minimal harm.
Report Facts
Effective date for denial of payments: Sep 10, 2015
Provider agreement termination date: Dec 10, 2015
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey results. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 10, 2014
Visit Reason
The Certification Health Survey was conducted to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The survey resulted in a finding of no deficiency citations with respect to the applicable regulations.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: N046091 POC SNW911
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection report dated 02.28.23 for Aspen Advanced Health Care.
Findings
The plan addresses multiple deficiencies including fall care plans, bathing plan adherence, chemical storage, and ice machine sanitation. Corrective actions include discharge of specific residents, staff education, audits, and revisions to care plans to ensure compliance.
Deficiencies (4)
Care plans for patients with falls have been reviewed and revised to include additional fall interventions.
Nursing staff educated on locating bathing plans and ensuring showers are offered according to care plans with proper documentation.
Chemicals have been stored appropriately and staff educated on proper storage to prevent risk to cognitively impaired residents.
Expired test strips disposed, ice machine lid closed, and staff educated on dishwasher sanitation chemical testing and documentation.
Report Facts
Audit frequency: 4
Audit frequency: 3
Substantial compliance target date: Apr 12, 2023
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