Inspection Reports for Delmar Gardens of Overland Park

An offsite revisit survey was conducted on 09/18/2018 to verify correction of all previous deficiencies cited on 08/02/2018.

All deficiencies cited in the previous inspection have been corrected as of the compliance date of 08/31/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted by Delmar Gardens of Overland Park in response to deficiencies cited in a prior inspection report.

The Plan of Correction addresses multiple deficiencies including notification to the State Long-Term Care Ombudsman, accuracy of resident assessments, development and implementation of person-centered care plans, respiratory care standards, food service safety, and proper garbage disposal. The facility outlines corrective actions, staff re-education, audits, and ongoing monitoring to ensure compliance.

A Recertification Survey was conducted including investigation of multiple complaint intake numbers in conjunction with this Recertification Survey.

The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified in areas including notice requirements before transfer/discharge, accuracy of assessments, comprehensive care planning, respiratory care, food safety, and garbage disposal.

Complaint Intake Numbers KS00126865, KS00126855, KS00126567, KS00126301, KS00124418, KS00123236, KS00118187, KS00111230, and KS00096883 were investigated in conjunction with this Recertification Survey.

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.

The survey found the most serious deficiencies to be a 'F' level deficiency, 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, and the facility was found to be in substantial compliance effective 08/31/2018.

This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.

All previously cited deficiencies were corrected as of the revisit date, with completion dates documented for each deficiency.

This report is a revisit conducted by a State surveyor to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.

The report confirms that the previously cited deficiency with regulation 28-39-158(a) was corrected as of 01/06/2017. No other deficiencies or findings are noted.

The inspection was conducted as a Health Resurvey and Complaint Investigation identified by #KS00101221 and #KS00099215.

The facility failed to have a Certified Dietary Manager (CDM) onsite for 4 of 4 days during the survey. Dietary staff who was not a CDM was performing duties including reviewing diets, preparing meals, and directing dietary staff.

The visit was triggered by a complaint investigation as indicated by the Health Resurvey and Complaint Investigation numbers #KS00101221 and #KS00099215.

This document is a Plan of Correction submitted by Delmar Gardens of Overland Park in response to deficiencies cited in a prior inspection report dated December 8, 2016.

The Plan of Correction addresses multiple deficiencies related to care plan revisions, fall interventions, dialysis care, accident hazard prevention, medication management, food safety, infection control, and drug regimen monitoring. The facility outlines corrective actions including staff education, audits, monitoring, and reporting to Quality Assurance committees to ensure compliance and resident safety.

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.

The survey found the most serious deficiencies to be an "F" level deficiency, 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 and was found to be in substantial compliance based on credible allegation of compliance and evidence of correction effective January 6, 2017.

This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

The report confirms that the previously cited deficiency related to regulation 483.25(m)(2) was corrected by 08/31/2016. No other deficiencies or uncorrected issues are noted.

This document is a Plan of Correction form submitted to show deficiencies previously reported on the CMS-2567 survey report have been corrected and the date such corrective action was accomplished.

The document lists multiple deficiencies identified by regulation numbers and indicates that corrections for these deficiencies were completed by 06/17/2016.

An Abbreviated Survey was conducted on August 2, 2016, by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiency at a level of actual harm, F333, 'G', which is not immediate jeopardy but requires corrections. Due to the facility's history of noncompliance from previous surveys in May 2016 and May 2015, no opportunity to correct deficiencies before remedies are imposed was granted.

The inspection was conducted as a complaint investigation (#102499) regarding medication errors at the facility.

The facility failed to monitor the placement and side effects of a Duragesic (fentanyl) patch for one resident, resulting in a significant medication error that caused narcotic overdose and hospitalization. Documentation and monitoring deficiencies related to the patch placement, removal, and witnessing by nursing staff were identified.

The complaint investigation #102499 found the facility failed to ensure residents were free of significant medication errors, specifically related to improper management of a Duragesic patch causing narcotic overdose and hospitalization of resident #1.

An Abbreviated Survey and a Life Safety Code survey were conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The surveys found serious deficiencies at a level of actual harm that is not immediate jeopardy, requiring corrections. Based on these deficiencies and the facility's history of noncompliance from the May 27, 2015 annual survey, the facility will not be given an opportunity to correct deficiencies before enforcement remedies are imposed.

An Abbreviated Survey and a Life Safety Code survey were conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The surveys found the most serious deficiencies at a level of actual harm that is not immediate jeopardy, requiring corrections. Due to the facility's history of noncompliance on the May 27, 2015 annual survey, no opportunity to correct deficiencies before remedies are imposed was granted.

The inspection was conducted as a complaint investigation (#98916) to evaluate the facility's compliance with care planning, services provided, and fall prevention interventions.

The facility failed to revise care plans to reflect discontinuation of therapy services for 2 of 3 sampled residents, failed to provide a physician ordered knee brace for 1 resident, and failed to implement fall prevention interventions resulting in a resident fall with tibia/fibula fractures and failure to place a high fall risk tag on another resident's wheelchair.

The visit was triggered by complaint investigation #98916.

This document is a Plan of Correction submitted by Delmar Gardens of Overland Park in response to deficiencies cited in a complaint survey.

The Plan of Correction addresses multiple deficiencies related to care plan accuracy, restorative program compliance, and clinical record maintenance. The facility outlines corrective actions including staff education, care plan audits, and ongoing monitoring and reporting to the Quality Assurance and Improvement Committee.

This Plan of Correction is in response to a complaint survey identified by Complaint ID 122315.

This post-certification revisit was conducted to verify that previously cited deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.

The revisit report shows that the deficiencies previously cited under regulations 483.20(d)(3), 483.10(k)(2), 483.25, and 483.75(l)(1) were corrected as of the revisit date.

An abbreviated 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.

The survey found the most serious deficiencies to be 'D' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan of correction.

The inspection was conducted as a complaint investigation covering multiple complaint investigation numbers (#88587, 93315, 94157, and 94683).

The facility failed to review and revise care plans for residents related to do not resuscitate status, falls, and elopement risk. Additionally, the facility failed to provide restorative/range of motion programs as ordered and failed to accurately document code status for a resident.

The inspection findings represent the results of complaint investigations #88587, 93315, 94157, and 94683.

This visit was conducted as a post-certification revisit to verify that previously identified deficiencies had been corrected.

The report documents that all previously cited deficiencies were corrected by 06/15/2015, with no uncorrected deficiencies remaining as of the revisit date.

A Health survey was conducted by the Kansas Department for Aging & Disability Services to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The facility was found not to be in substantial compliance, with conditions constituting immediate jeopardy to resident health or safety from April 25, 2015 through May 27, 2015. Deficiencies were severe enough to warrant denial of payment for all new Medicare admissions effective June 16, 2015.

The inspection was conducted as a Health Resurvey, Extended Health Survey and Complaint Investigation related to allegations of abuse and neglect, falls, and other compliance issues.

The facility failed to protect residents from abuse, failed to investigate and report allegations of abuse, failed to provide medically-related social services to address abuse, failed to update care plans for falls and dental appliance changes, failed to complete neurological assessments after un-witnessed falls, failed to provide proper oral care, failed to implement appropriate wound care interventions, failed to prevent accidents and falls, failed to properly clean resident rooms to prevent infection, and failed to provide timely laboratory services.

The complaint investigation included allegations of verbal abuse and neglect of resident #61, failure to investigate and report abuse, falls with injury and lack of appropriate interventions, inadequate wound care, infection control issues, and failure to provide timely laboratory services.

The document is a Plan of Correction submitted by Delmar Gardens of Overland Park in response to deficiencies cited during a prior inspection, including allegations of verbal abuse and injury investigations.

The Plan of Correction details the facility's actions to address allegations of verbal abuse, injury investigations including rib fractures, staff re-education on abuse and neglect policies, resident safety monitoring, care plan updates, infection control, and laboratory service compliance.

This is a post-certification revisit to verify that previously identified deficiencies have been corrected as shown on the CMS-2567 Statement of Deficiencies and Plan of Correction.

The report documents that deficiencies previously cited under regulations 483.20(b)(1), 483.20(d), 483.20(k)(1), and 483.60(a),(b) were corrected as of the revisit date.

This Plan of Correction document was submitted in response to deficiencies cited during a complaint investigation survey at Delmar Gardens of Overland Park.

The Plan of Correction addresses deficiencies related to incomplete comprehensive assessments (CAAs), integration of hospice services into care plans, and pharmaceutical services including medication administration and documentation.

This Plan of Correction is related to a complaint investigation survey as indicated by the reference to the complaint and audit of assessments following the complaint.

An abbreviated 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.

The survey found the most serious deficiencies to be 'D' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.

The inspection was conducted as a complaint investigation based on complaint investigation numbers #77010 and #75789.

The facility failed to ensure accurate and comprehensive assessments and care plans for residents, specifically related to hospice services for resident #3. Additionally, the facility failed to provide pharmaceutical services meeting the needs of residents #1 and #3, with multiple instances of medication administration not documented or refused.

The citations represent findings from complaint investigations #77010 and #75789.

This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.

The report documents that deficiencies identified under regulations 483.25 and 483.60(a),(b) were corrected as of the revisit date, May 23, 2014.

This document is a Plan of Correction submitted by Delmar Gardens of Overland Park in response to deficiencies cited in a complaint survey.

The Plan of Correction addresses deficiencies related to pain assessment and management, medication administration, and physician order transcription. The facility outlines corrective actions including staff re-education, auditing medical records, and ongoing monitoring by the Director of Nursing and QAPI Committee.

The inspection was conducted as a complaint investigation (#75125) regarding the facility's failure to provide timely and effective pain management for residents.

The facility failed to adequately assess and manage pain for 3 sampled residents, including failure to document pain assessments, monitor response to pain medication, and properly transcribe physician orders for pain medication.

The complaint investigation #75125 focused on pain management issues for 3 residents, substantiating failures in pain assessment, documentation, medication administration, and transcription of physician orders.

This is a post-certification revisit to verify that previously cited deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.

The report confirms that all previously identified deficiencies listed with their regulation numbers have been corrected as of the revisit date.

This post-certification revisit was conducted to verify that previously cited deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

The revisit confirmed that all previously cited deficiencies listed with their regulation numbers were corrected as of the revisit date.

The inspection was conducted as a Non-compliance Revisit and Complaint investigation #73315 to assess compliance with pharmaceutical service procedures.

The facility failed to follow physician's orders for one resident (#8) by continuing to administer discontinued medications (Vitamin C, Vitamin B12, and Simvastatin) for nearly two months after the physician ordered their discontinuation. The facility also lacked a policy regarding transcription of medication orders.

The visit was triggered by a complaint investigation #73315 and was a Non-compliance Revisit.

This is a post-certification revisit to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.

All previously cited deficiencies listed with their regulation numbers were corrected by 03/05/2014 as verified during this revisit.

This document is a Plan of Correction submitted by Delmar Gardens of Overland Park in response to deficiencies cited in a prior survey.

The Plan of Correction addresses pharmaceutical service deficiencies, including accurate acquiring, receiving, dispensing, and administering of medications. It outlines corrective actions such as re-education of nursing staff, auditing medical records, and reporting to the QAPI Committee.

This document is a Plan of Correction submitted by Delmar Gardens of Overland Park in response to deficiencies cited in a prior survey, outlining corrective actions to address identified issues.

The Plan of Correction details multiple corrective actions including re-inservicing staff on residents' rights, dignity, care plans, dietary preferences, infection control, medication monitoring, fall prevention, pressure ulcer prevention, and maintenance of a safe environment. It includes timelines for completion and ongoing monitoring through the QAPI Committee.

The inspection was conducted as a Health Resurvey and Complaint Investigation to assess compliance with regulatory requirements.

The facility was found deficient in multiple areas including dignity and respect, self-determination, housekeeping, comprehensive assessments, care planning, pressure sore prevention and treatment, medication management, infection control, and resident call system functionality.

The inspection included a complaint investigation as indicated by the initial comments and the nature of the deficiencies found related to resident care and facility compliance.

This revisit report documents the correction of previously cited deficiencies at Delmar Gardens of Overland Park, verifying that corrective actions were completed as of the revisit date.

The report confirms that the deficiencies previously reported under regulation numbers 28-39-158(a) and 26-40-303 (2)(a)(i)(ii)(iii) were corrected by the revisit date of 11/08/2012.

This is a post-certification revisit to verify that previously cited deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.

The report confirms that all previously identified deficiencies have been corrected as of the revisit date, with corrections completed on 11/08/2012 for multiple regulatory items.

This document is a Plan of Correction submitted by Delmar Gardens of Overland Park in response to deficiencies cited during a prior inspection, outlining corrective actions to address identified issues.

The Plan of Correction details multiple areas for improvement including activity assessments, comprehensive care plan updates, medication regimen reviews, drug labeling and expiration monitoring, dietetic services oversight, and exit door safety compliance. The facility requests waivers of time to complete some corrective actions within 90 days.

The inspection was a health resurvey to assess compliance with dietary services and door monitoring system regulations.

The facility failed to have a full-time certified dietary manager on site for 5 of 5 days and failed to ensure that all exit doors, specifically the therapy room exit door, were electronically monitored and functioning properly.

This is a post-certification revisit to verify that previously identified deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.

The report confirms that the deficiency identified under regulation 483.25(l) with ID prefix F0329 was corrected on 05/09/2012.

This document is a Plan of Correction submitted by Delmar Gardens of Overland Park in response to deficiencies cited in a prior survey, addressing medication regimen monitoring and documentation.

The Plan of Correction outlines corrective actions including in-service education for nursing staff, audits of medication documentation, and ongoing review of residents' medication regimens to ensure appropriate monitoring and reporting of vital signs related to anti-hypertensive medications.

The inspection was conducted as a complaint investigation (#KS55657) focusing on the facility's compliance with drug regimen requirements, specifically monitoring and parameters for hypertensive medications.

The facility failed to provide adequate blood pressure (BP) parameters for hypertensive medications and failed to monitor pulse as ordered for three of four sampled residents. Documentation and monitoring deficiencies were noted in admission orders, care plans, and medication administration records.

Complaint investigation #KS55657 focused on drug regimen and medication monitoring compliance.

This is a post-certification revisit conducted to verify that previously identified deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.

All deficiencies previously cited in the initial survey have been corrected as of the revisit date, with corrections completed for multiple regulatory requirements.

Health Resurvey to assess compliance with regulatory requirements and to verify correction of previous deficiencies.

The facility was found deficient in multiple areas including failure to provide reasonable accommodation of resident needs, failure to revise care plans after falls, inadequate care for urinary incontinence, failure to prevent accidents due to improper use of assistive devices, failure to manage medication regimens properly, and failure to label and date medications appropriately.

This Plan of Correction is submitted in response to deficiencies cited in the Delmar Gardens complaint inspection dated 08/02/2016, addressing medication errors related to Duragesic patch administration and documentation.

The facility identified issues with medication errors involving Duragesic patches, including documentation of site placement, monitoring, removal, and destruction. The Plan of Correction outlines steps for review, staff re-education, care plan revisions, and ongoing monitoring to ensure compliance and prevent significant medication errors.

This Plan of Correction is in response to a complaint investigation related to medication errors involving Duragesic patches.