Inspection Reports for Brookdale College Square
11000 OAKMONT ST, OVERLAND PARK, KS, 66210
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 9, 2024, found the facility in compliance with all regulations and no new deficiencies. Earlier inspections showed a pattern of isolated deficiencies primarily related to medication administration and documentation, as well as issues with timely reporting and investigation of abuse allegations. Complaint investigations substantiated failures in medication administration in September 2024 and in abuse reporting and tuberculosis testing in August 2022. Enforcement actions included an immediate jeopardy finding in May 2021 related to abuse allegations, which was resolved by transferring the involved resident; fines or license suspensions were not listed in the available reports. The facility appears to have addressed recent deficiencies promptly, with the latest inspection confirming correction of prior issues.
Deficiencies (last 10 years)
Deficiencies (over 10 years)
2.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
63% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
41 residents
Based on a September 2024 inspection.
Occupancy over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 9, 2024
Visit Reason
An offsite revisit survey was conducted on 10/09/24 to verify correction of all previous deficiencies cited on 09/23/24.
Findings
All deficiencies have been corrected as of the compliance date of 09/25/24 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: Deficiencies cited on 09/23/24 and corrected by 09/25/24
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 1
Date: Sep 23, 2024
Visit Reason
The inspection was a resurvey with attached complaints #188583, #186864, and #184634 conducted at the assisted living facility on 09/19/2024 and 09/23/2024.
Complaint Details
The visit was complaint-related involving complaints #188583, #186864, and #184634. The findings substantiated that the facility did not comply with medication administration orders for Resident 1.
Findings
The facility failed to ensure that staff administered all medications to Resident 1 in accordance with her medical care provider's orders, specifically regarding the administration of midodrine and documentation of blood pressure readings before medication administration.
Deficiencies (1)
Facility staff administered midodrine to Resident 1 despite systolic blood pressures being above 140 mm Hg, contrary to medical orders, and failed to document blood pressure results every morning before administering midodrine.
Report Facts
Census: 41
Medication administration dates with systolic BP above 140: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Confirmed facility staff failed to administer midodrine according to medical orders on 09/23/24 |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
The document represents the findings of a resurvey with attached complaints #188583, #186864, and #184634 at the assisted living facility conducted on 09/19/24 and 09/23/24.
Complaint Details
The resurvey was conducted with attached complaints #188583, #186864, and #184634.
Findings
This plan of correction addresses the findings from the resurvey and attached complaints conducted on the specified dates.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 5, 2023
Visit Reason
The abbreviated survey was conducted on 06/05/2023 at the assisted living facility in response to complaints #180497, 180550, 180458, 180450, and 176794.
Complaint Details
The survey was complaint-related, addressing multiple complaints, and found no deficiencies.
Findings
The survey resulted in a finding of no deficiency citations at the facility.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 5, 2023
Visit Reason
The abbreviated survey was conducted on 06/05/23 for complaints #180497, 180550, 180458, 180450, and 176794 at the assisted living facility.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 6, 2022
Visit Reason
The abbreviated survey was conducted in response to multiple complaint numbers at the assisted living facility on 12/05/22 and 12/06/22.
Complaint Details
The survey was complaint-related, covering complaint numbers 176480, 176448, 176267, 176254, 176057, 175606, 175323, and 175043, with no deficiencies found.
Findings
The survey resulted in a finding of no deficiency citations at the facility.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 5, 2022
Visit Reason
The document is a plan of correction related to an abbreviated survey conducted on 12/05/22 and 12/06/22 at an assisted living facility, addressing multiple complaint numbers.
Findings
The abbreviated survey for the listed complaint numbers resulted in a finding of no deficiency citations.
Report Facts
Complaint numbers referenced: 8
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 21, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 08/30/22.
Findings
All deficiencies have been corrected as of the compliance date of 09/13/22, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 2
Date: Aug 29, 2022
Visit Reason
The inspection was conducted as a licensure resurvey with attached complaint investigations numbered 174332, 173949, and 173563 on 08/29/22 and 08/30/22.
Complaint Details
The visit was complaint-related involving allegations of sexual abuse to resident R112. The complaint was substantiated by findings that the facility failed to timely report and investigate the allegation as required.
Findings
The facility failed to report an allegation of sexual abuse involving resident R112 to the department within 24 hours and did not submit the full investigation within five working days. Additionally, the facility failed to comply with tuberculosis (TB) testing guidelines for newly hired employees, missing required timing for the two-step TB skin test.
Deficiencies (2)
Failure to report an allegation of sexual abuse on resident R112 to the department within 24 hours and failure to submit the full investigation within five working days.
Failure to comply with tuberculosis (TB) guidelines by not performing the first step of the two-step TB skin test within seven days of employment and not conducting the second step within one to three weeks for five newly hired/current employees.
Report Facts
Census: 64
Complaint numbers: 3
Sample size: 6
Sample size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Interviewed and confirmed failure to report sexual abuse allegation within 24 hours and failure to submit full investigation within five working days |
| Operator F | Operator | Interviewed and confirmed failures in TB testing compliance for newly hired employees |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 29, 2022
Visit Reason
The document is a plan of correction responding to findings from a licensure resurvey with attached complaint numbers 174332, 173949, and 173563 conducted on 08/29/22 and 08/30/22.
Complaint Details
The plan of correction is related to complaints numbered 174332, 173949, and 173563 attached to the licensure resurvey.
Findings
The plan of correction addresses citations identified during the licensure resurvey and complaint investigations conducted on the specified dates.
Report Facts
Complaint numbers: 3
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 9, 2022
Visit Reason
The abbreviated resurvey was conducted for complaint numbers 168144 and 165594 on 2/8/2021 and 2/9/2021 at the assisted living facility.
Complaint Details
The visit was complaint-related for complaints #168144 and #165594 and resulted in no deficiencies.
Findings
The abbreviated resurvey resulted in a finding of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Jun 7, 2021
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies at Brookdale College Square have been corrected and to document the dates such corrective actions were accomplished.
Findings
The report indicates that the deficiencies previously cited under regulations 26-41-101 (f)(3) and 26-41-204 (a) were corrected as of June 7, 2021. No uncorrected deficiencies were noted at the time of this revisit.
Deficiencies (2)
Deficiency related to regulation 26-41-101 (f)(3)
Deficiency related to regulation 26-41-204 (a)
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 2
Date: May 5, 2021
Visit Reason
The inspection was conducted for re-licensure with attached complaints #42554, #49735, #51873, #55100, and #61881 over multiple days in May 2021 at an assisted living facility in Overland Park, KS.
Complaint Details
The investigation was triggered by multiple complaints (#42554, #49735, #51873, #55100, and #61881) related to allegations of sexual abuse and neglect involving resident #111 and other residents (#108, #109, #110). The facility failed to report incidents timely and failed to conduct proper investigations.
Findings
The facility failed to immediately implement corrective measures to prevent further potential sexual abuse, failed to report allegations of abuse within 24 hours, and failed to initiate timely investigations. Resident #111 exhibited inappropriate sexual behaviors towards multiple female residents, and the facility did not adequately address these behaviors or coordinate necessary health care services, placing residents in immediate jeopardy. The immediate jeopardy was removed when resident #111 was discharged to a geriatric-psych behavior health facility.
Deficiencies (2)
Failure to immediately implement corrective measures to prevent further potential sexual abuse, failure to report allegations within 24 hours, and failure to initiate investigations as required.
Failure to ensure licensed nurse provided and coordinated necessary health care services to meet residents' needs in accordance with functional capacity screening and negotiated service agreement.
Report Facts
Census: 44
Dates of incidents: Multiple incident dates including 4/8/21, 4/27/21, 4/30/21, and others documented in nursing notes.
Medication dosages: 50
Medication dosages: 25
Medication dosages: 1
Medication dosages: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse #B | Administrative Nurse | Confirmed receipt of resident records, acknowledged failure to report abuse within 24 hours, and involved in medication orders and supervision. |
| CNA #C | Certified Nursing Assistant | Provided notarized statement regarding witnessing inappropriate touching by resident #111. |
| Activity Staff #D | Activity Staff | Provided notarized statement regarding observation of resident #111 near another resident's bed. |
| Operator #A | Operator | Provided notarized statement regarding plans for resident #111's placement and supervision. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 9, 2021
Visit Reason
The abbreviated resurvey was conducted on 2/8/2021 and 2/9/2021 in response to complaints #168144 and #165594 at the assisted living facility.
Complaint Details
The visit was complaint-related for complaints #168144 and #165594, and no deficiencies were found.
Findings
The abbreviated resurvey resulted in a finding of no deficiency citations.
Inspection Report
Routine
Deficiencies: 0
Date: Aug 7, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 2020-08-07.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Jan 16, 2019
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies at Brookdale College Square were corrected and to document the dates such corrective actions were accomplished.
Findings
The report indicates that all previously cited deficiencies identified by regulation numbers 26-41-102(d) and 26-41-207(b)(5-6)(c) were corrected as of the revisit date.
Deficiencies (2)
Deficiency related to regulation 26-41-102(d)
Deficiency related to regulation 26-41-207(b)(5-6)(c)
Inspection Report
Renewal
Census: 56
Deficiencies: 2
Date: Dec 13, 2018
Visit Reason
The inspection was conducted for re-licensure with attached complaints at the assisted living facility in Overland Park, KS on 12/11/18, 12/12/18, and 12/13/18.
Complaint Details
The survey was conducted with attached complaints, indicating complaint-related issues were part of the inspection.
Findings
The facility failed to ensure employee records contained timely supporting documentation for criminal background checks and nurse aide registry verification for certified staff. Additionally, the facility did not comply with tuberculosis testing guidelines for staff, lacking required TB skin tests and documentation.
Deficiencies (2)
Employee records lacked timely supporting documentation from the nurse aide registry and criminal background checks for certified staff.
Failure to comply with tuberculosis guidelines for adult care homes, including missing TB skin tests and incomplete documentation for recent staff hires.
Report Facts
Census: 56
Sample size: 4
Closed chart reviews: 3
Focus review residents: 1
Days after hire for KBI check - Staff E: 16
Days after hire for KBI check - Staff D: 1
Days after hire for KBI check - Staff F: 2
Days after hire for KBI check - Staff G: 9
Inspection Report
Re-Inspection
Census: 51
Deficiencies: 8
Date: Nov 8, 2016
Visit Reason
The inspection was a Licensure Resurvey conducted over multiple days including complaint investigation #94773.
Complaint Details
Complaint #94773 was also investigated during this resurvey.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy with use of audio electronic monitors, inaccurate functional capacity screenings, failure to revise negotiated service agreements after significant changes, lack of signatures on service agreements, inadequate licensed nurse coordination of health care services, incomplete documentation of incidents, and failure to conduct quarterly emergency management plan reviews with employees and residents.
Deficiencies (8)
Failure to develop and implement policy and procedure to ensure residents' right to privacy and confidentiality related to use of audio electronic monitors transmitting to open kitchens.
Failure to ensure functional capacity screens accurately reflected residents' current needs.
Failure to review and revise negotiated service agreements following significant changes in condition.
Failure to ensure all individuals involved in development of negotiated service agreements signed the agreements.
Failure to ensure licensed nurse provided or coordinated necessary health care services meeting residents' needs.
Failure to include description of health care services and name of licensed nurse responsible in negotiated service agreements.
Failure to document all incidents, symptoms, and indications of illness or injury including date, time, action taken, and results.
Failure to conduct quarterly reviews of the facility's emergency management plan with employees and residents.
Report Facts
Census: 51
Employees hired since last resurvey: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Operator #L | Interviewed regarding use of audio electronic monitors and emergency management plan reviews | |
| Health and Wellness Director #M | Interviewed regarding functional capacity screens, negotiated service agreements, health care services, and emergency management plan reviews | |
| Certified Staff #P | Observed assisting residents with transfers and personal care | |
| Certified Staff #K | Observed assisting residents with transfers and personal care | |
| Certified Staff #F | Observed feeding and assisting residents, and fall prevention measures | |
| Licensed Practical Nurse #Q | LPN | Observed assisting resident and interviewed about fall prevention plan |
Inspection Report
Renewal
Census: 42
Deficiencies: 3
Date: Dec 11, 2014
Visit Reason
The inspection was a Licensure Resurvey conducted at the Residential Health Care Facility in Overland Park, Kansas on 12/09/14, 12/10/14, and 12/11/14 to assess compliance with state regulations.
Findings
The facility failed to ensure designated staff conducted functional capacity screenings following significant changes in residents' conditions and failed to develop complete negotiated service agreements (NSA) for residents based on their needs and preferences. Additionally, the NSAs lacked required signatures from residents or their legal representatives.
Deficiencies (3)
Failure to conduct functional capacity screening following significant change in condition for residents #187 and #189.
Failure to develop written negotiated service agreements for residents #189, #187, and #185 that included descriptions of services to be received.
Failure to ensure all individuals involved in the development of the negotiated service agreements signed the agreements for residents #189 and #185.
Report Facts
Census: 42
Sampled Residents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Facility Nurse G | Facility Nurse | Confirmed lack of updated functional capacity screening and NSA signatures. |
| Operator C | Operator | Confirmed lack of NSA signatures and discussed family contact. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 17, 2012
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified by ASPEN Event ID 95T811 and State ID N046047.
Findings
No specific deficiencies or findings are detailed in this document; it serves as a record of the Plan of Correction submission and related administrative data.
Report Facts
Plan of Correction added date: POC added on 05/01/2012 12:45:03 PM
Inspection start date: Inspection start date 04/17/2012
Inspection exit date: Inspection exit date 04/19/2012
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