Inspection Reports for
Delmar Gardens of Overland Park
12100 W. 109TH STREET, OVERLAND PARK, KS, 66210-1200
Back to Facility ProfileDeficiencies (last 10 years)
Deficiencies (over 10 years)
24.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
302% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
68% occupied
Based on a March 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 81
Deficiencies: 32
Date: Mar 13, 2024
Visit Reason
Routine inspection of Delmar Gardens of Overland Park nursing home to assess compliance with regulatory requirements related to resident care, medication management, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide dignified care, incomplete resident assessments, inadequate care planning, improper medication management, failure to maintain infection control standards, unsafe resident transfers, and insufficient staff education. These deficiencies placed residents at risk for impaired dignity, unmanaged pain, preventable injuries, infections, and decreased quality of life.
Deficiencies (32)
F550: The facility failed to treat residents with dignity during dining and catheter care, placing residents at risk for impaired dignity and quality of life.
F553: The facility failed to include a resident in care plan development, risking impaired care and autonomy.
F558: The facility failed to accommodate resident needs and preferences related to call light accessibility and bathing, risking impaired care and autonomy.
F565: The facility failed to adequately address recurring Resident Council concerns, risking decreased psychosocial well-being and quality of life.
F576: The facility failed to ensure resident privacy when a resident's package was opened before delivery, risking impaired privacy and autonomy.
F582: The facility failed to issue required Medicare Advance Beneficiary Notification forms for discharged residents, risking decreased autonomy and impaired decision-making.
F585: The facility failed to implement an anonymous grievance system and maintain grievance records, risking unresolved grievances and decreased psychosocial well-being.
F623: The facility failed to provide timely written notification of facility-initiated transfers to residents, representatives, and the Long-Term Care Ombudsman, risking miscommunication and missed healthcare opportunities.
F625: The facility failed to provide bed hold notifications with required information upon resident transfers, risking impaired ability to return to the facility or same room.
F636: The facility failed to complete comprehensive Minimum Data Set Section V Care Area Assessments for multiple residents, risking inaccurate care planning.
F637: The facility failed to complete a comprehensive Significant Change MDS for a resident after hospice admission, risking unidentified care needs.
F641: The facility failed to accurately document a resident's restraint status on the MDS, risking inappropriate care planning.
F655: The facility failed to identify required care assistance levels and high-risk medications on baseline care plans for residents, risking preventable falls and injuries.
F656: The facility failed to develop comprehensive care plans reflecting residents' personal preferences and care needs, risking impaired care.
F677: The facility failed to provide assistance with personal hygiene including facial hair trimming, risking poor hygiene and impaired dignity.
F684: The facility failed to maintain residents' highest practicable physical function and comfort, including failure to apply protective sleeve and provide restorative services, risking impairment and skin injury.
F686: The facility failed to provide appropriate pressure ulcer care including proper mattress settings and pressure-relieving devices, risking skin breakdown and ulcers.
F688: The facility failed to apply a prescribed splint as directed, risking reduced range of motion and mobility.
F689: The facility failed to maintain a safe environment by unsecured chemicals and improper wheelchair foot pedal use, risking preventable accidents and injuries.
F695: The facility failed to provide adequate respiratory care including clarifying BiPAP settings and sanitary storage of equipment, risking respiratory infections and complications.
F697: The facility failed to recognize, evaluate, and manage a resident's pain, resulting in unmanaged pain and risk for impaired mobility and quality of life.
F755: The facility failed to consistently reconcile controlled drugs at shift changes, risking medication misappropriation.
F756: The facility failed to ensure the consultant pharmacist identified and reported medication irregularities including lack of indications and failure to notify physicians of abnormal blood sugars, risking unnecessary medication and adverse effects.
F757: The facility failed to ensure medications had indications for use, risking unnecessary medication administration and adverse side effects.
F758: The facility failed to implement gradual dose reductions and ensure psychotropic medications had indications, risking unnecessary medication and adverse effects.
F806: The facility failed to accommodate a resident's dietary preferences for diabetic-friendly foods, risking impaired autonomy and quality of life.
F812: The facility failed to properly label, date, and store food items and tableware, and failed to monitor food and dishwasher temperatures, risking foodborne illness.
F880: The facility failed to follow infection control standards including disinfecting shared equipment, sanitary storage of respiratory equipment, using appropriate disinfectants for C-diff, and posting correct isolation signs, risking infectious disease complications.
F882: The facility failed to designate a qualified and certified Infection Preventionist, risking inadequate infection identification and control.
F943: The facility failed to offer and educate residents on pneumococcal vaccination as recommended, risking pneumococcal disease complications.
F947: The facility failed to provide required abuse, neglect, and exploitation prevention training to some Certified Nurse Aides, risking inadequate staff knowledge and resident safety.
F947 (continued): The facility failed to ensure all CNAs had required in-service education including dementia care, risking inadequate care.
Report Facts
Residents present (census): 81
Residents reviewed in sample: 21
Residents with controlled substances on cart: 16
Dates with missing narcotic reconciliation: 16
Blood sugar below ordered parameters: 2
Hours of in-service education for CNA LL: 8
Hours of in-service education for CNA OO: 6
Hours of in-service education for CNA PP: 0
Hours of in-service education for CNA QQ: 0
Hours of in-service education for CNA RR: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse L | Licensed Nurse | Named in dignity and dining assistance deficiency for Resident R16 |
| Certified Nurse Aide N | Certified Nurse Aide | Named in dignity, call light, bathing, respiratory care, and transfer safety deficiencies |
| Licensed Nurse K | Licensed Nurse | Named in dignity, care planning, medication management, and transfer safety deficiencies |
| Administrative Nurse D | Administrative Nurse | Named in multiple deficiencies including dignity, care planning, medication management, infection control, and transfer safety |
| Certified Nurse Aide O | Certified Nurse Aide | Named in transfer safety deficiency involving Hoyer lift incident |
| Licensed Nurse KK | Licensed Nurse | Named in transfer safety deficiency involving Hoyer lift incident |
| Administrative Staff A | Administrative Staff | Named in transfer notification, grievance system, education tracking, and infection control deficiencies |
| Administrative Staff B | Administrative Staff | Named in transfer notification, grievance system, education tracking, and infection control deficiencies |
| Certified Nurse Aide PP | Certified Nurse Aide | Named in staff education deficiency |
| Certified Nurse Aide QQ | Certified Nurse Aide | Named in staff education deficiency |
Inspection Report
Routine
Census: 81
Deficiencies: 28
Date: Mar 13, 2024
Visit Reason
Routine inspection of Delmar Gardens of Overland Park nursing home to assess compliance with regulatory requirements including resident care, safety, medication management, infection control, and staff training.
Findings
The facility had multiple deficiencies including failure to provide dignified care, incomplete care planning, inadequate medication management, unsafe environment hazards, insufficient staff training, and infection control lapses. Several residents' rights and care needs were not fully met, placing them at risk for harm.
Deficiencies (28)
F550: The facility failed to provide dignified care to residents R16 and R286, including improper catheter bag handling and staff positioning during meals.
F553: The facility failed to include resident R12 in care plan development, risking impaired care and autonomy.
F558: The facility failed to reasonably accommodate residents R80 and R12's needs and preferences, including call light placement and bathing schedules.
F565: The facility failed to adequately address and resolve recurring Resident Council concerns, risking decreased psychosocial well-being.
F576: The facility failed to ensure resident R81's right to private communications when her package was opened and contents removed.
F582: The facility failed to issue required Medicare Advance Beneficiary Notices to residents R12 and R18, risking impaired decision-making.
F623: The facility failed to notify residents R16 and R43, their representatives, and the Long-Term Care Ombudsman of facility-initiated transfers, and failed to provide timely written transfer notices.
F625: The facility failed to provide bed hold notifications with required information to residents R16 and R43 and their representatives upon hospital transfers.
F636: The facility failed to complete comprehensive MDS Section V Care Area Assessments for multiple residents, risking inaccurate care planning.
F637: The facility failed to complete a comprehensive Significant Change MDS for resident R24 after hospice admission, risking unidentified care needs.
F641: The facility failed to complete an accurate MDS assessment for resident R47 regarding restraint use, documenting a trunk restraint without order or assessment.
F655: The facility failed to develop baseline care plans identifying resident R82's level of care and high-risk medication Seroquel, and failed to complete a baseline care plan for R81.
F656: The facility failed to develop comprehensive care plans for residents R80, R30, and R81, lacking documentation of care needs, preferences, and treatments.
F677: The facility failed to provide necessary assistance with personal hygiene for resident R30, including failure to assist with trimming facial hair.
F684: The facility failed to provide services to maintain resident R31's highest practicable level of physical function and comfort, including failure to implement positioning wedges.
F688: The facility failed to apply a protective sleeve to resident R67's right arm as ordered, risking skin injury.
F689: The facility failed to ensure chemicals were secured and out of reach of residents, and failed to use safe mechanical lift techniques for residents R61, R17, and R30.
F695: The facility failed to provide adequate respiratory care for resident R12, including lack of order clarity and sanitary storage of respiratory equipment.
F697: The facility failed to recognize, evaluate, manage, and treat pain for resident R286, resulting in unmanaged pain and risk for impaired mobility.
F755: The facility failed to provide consistent controlled drug reconciliation at shift changes, risking medication misappropriation.
F756: The facility failed to ensure the consultant pharmacist identified and reported irregularities in medication indications and physician notifications for resident R16.
F757: The facility failed to ensure psychotropic medications for resident R16 had indications for use, risking unnecessary medication administration.
F806: The facility failed to provide food substitutions accommodating resident R3's preferences, risking impaired autonomy and decreased quality of life.
F812: The facility failed to ensure proper food storage, labeling, temperature monitoring, and sanitary handling of tableware and plates, risking foodborne illness.
F880: The facility failed to ensure proper infection control related to disinfecting shared equipment, respiratory equipment storage, use of appropriate disinfectants for C-diff, and posting correct isolation precautions for resident R236.
F882: The facility failed to designate a qualified infection preventionist responsible for the infection prevention and control program.
F943: The facility failed to provide required abuse, neglect, and exploitation prevention training for two of five sampled Certified Nurse Aides.
F947: The facility failed to ensure Certified Nurse Aides had required skills and education in dementia care and abuse prevention.
Report Facts
Residents affected: 81
Residents reviewed: 21
Controlled drug reconciliation missing: 16
Narcotic reconciliation missing shifts: 16
In-service education hours missing: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA PP | Certified Nurse Aide | Lacked required abuse, neglect, and exploitation training |
| CNA QQ | Certified Nurse Aide | Lacked required abuse, neglect, and exploitation training |
| LN KK | Licensed Nurse | Involved in Hoyer lift incident with resident R17 |
| CNA O | Certified Nurse Aide | Involved in Hoyer lift incident with resident R17; re-educated and competency checked |
| Administrative Nurse D | Administrative Nurse | Provided multiple statements on care plans, medication, infection control, and staff training |
| Administrative Staff A | Administrative Staff | Provided statements on education tracking, transfer notifications, and infection control |
| Administrative Staff B | Administrative Staff | Provided statements on education records and transfer notifications |
| Licensed Nurse K | Licensed Nurse | Provided statements on medication administration and care plans |
| Certified Nurse Aide N | Certified Nurse Aide | Provided statements on care assistance and infection control |
| Licensed Nurse G | Licensed Nurse | Provided statements on mattress settings and infection control |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 12
Date: Sep 15, 2022
Visit Reason
The inspection was conducted based on complaints and observations regarding resident dignity, grievance resolution, behavior management, medication administration, medication storage, food preparation, and infection control practices at the facility.
Complaint Details
The visit was complaint-related, triggered by concerns about resident dignity, grievance handling, behavior management, medication administration, expired medications, food preparation, and infection control. The complaints were substantiated by observations, interviews, and record reviews.
Findings
The facility was found deficient in multiple areas including failure to provide dignity during meals, unresolved resident grievances, inaccurate behavioral assessments, inadequate behavior interventions, improper medication administration and monitoring, failure to dispose expired medications, improper food handling and preparation, and unsafe chemical storage. These deficiencies placed residents at risk for psychosocial harm, unresolved concerns, worsened behaviors, medication errors, physical complications, and foodborne illness.
Deficiencies (12)
F0550: The facility failed to provide dignity and respect during dining for Resident 83, placing her at risk for an undignified experience.
F0585: The facility failed to follow-up or resolve resident grievances, placing residents at risk for unresolved concerns.
F0641: The facility failed to accurately code the Minimum Data Set to reflect Resident 87's behaviors, placing the resident at risk for continued and worsened behaviors.
F0675: The facility failed to provide necessary behavior cares and services for Resident 87, placing affected residents at risk for increased stress, discomfort, and social isolation.
F0689: The facility failed to secure chemicals in a locked cabinet, placing 19 cognitively impaired residents at risk for accidents.
F0740: The facility failed to implement interventions to redirect Resident 87's behaviors as directed by her care plan, placing the resident at risk for worsened behaviors.
F0756: The facility failed to ensure the consultant pharmacist identified and reported staff's failure to correctly hold or administer blood pressure medication for Resident 18, placing the resident at risk for uncontrolled blood pressures and unnecessary medication use.
F0757: The facility failed to correctly hold or administer blood pressure medication for Resident 18 as directed by the physician, placing the resident at risk for uncontrolled blood pressures and unnecessary medication use.
F0758: The facility failed to provide a stop date or rationale for extended use for PRN psychotropic medications for Residents 2 and 87, placing them at risk for unnecessary medication use and adverse side effects.
F0761: The facility failed to dispose of expired Juven nutrition powder and antibiotic medication, placing residents at risk for physical complications and ineffective treatment.
F0804: The facility failed to follow a recipe during puree preparation for five residents, placing them at risk for altered nutritional status and unpalatable food.
F0812: The facility failed to properly handle silverware and dishes, maintain a functioning sink sprayer, and ensure clean pipes under the sink, placing residents at risk for foodborne illness.
Report Facts
Residents present: 88
Sample residents reviewed: 18
Residents affected by chemical storage deficiency: 19
Residents receiving meals from facility kitchen: 84
Expired Juven packets: 4
Expired antibiotic vials: 11
Times midodrine held correctly: 18
Times midodrine incorrectly administered: 5
Times no blood pressure documented: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified multiple deficiencies including dignity, grievance follow-up, behavior management, medication administration, chemical storage, and food handling |
| Certified Medication Aide S | Certified Medication Aide | Administered medications to Resident 18 and verified expired Juven packets |
| Licensed Nurse G | Licensed Nurse | Verified chemical storage deficiency and described Resident 87's behaviors |
| Licensed Nurse H | Licensed Nurse | Stated staff were to hold midodrine if SBP was greater than 120 |
| Dietary BB | Dietary Staff | Prepared pureed diet without following recipe and handled silverware improperly |
| Dietary CC | Dietary Staff | Handled silverware improperly and left soiled clothing protectors on floor |
Inspection Report
Annual Inspection
Census: 100
Deficiencies: 8
Date: Apr 15, 2021
Visit Reason
Annual inspection of Delmar Gardens of Overland Park nursing home to assess compliance with healthcare regulations and resident care standards.
Findings
The facility had multiple deficiencies including failure to maintain appropriate wheelchair positioning, inadequate pressure ulcer care and nutritional support, incomplete safety assessments for residents, improper use of lift slings, failure to follow dietitian recommendations, improper feeding tube care, failure to provide ordered medications, medication storage and labeling issues, and inadequate housekeeping and maintenance services.
Deficiencies (8)
F0684: The facility failed to provide necessary assessments, treatments, and cares for Resident 28 to maintain appropriate wheelchair positioning, placing the resident at risk for decreased mobility and pain.
F0686: The facility failed to provide nutritional supplements and implement protective interventions to assist wound healing for Resident 28, placing the resident at risk for worsened wound conditions.
F0689: The facility failed to complete a smoking assessment for Resident 41, failed to initiate safety assessments for an electric lift recliner for Resident 82 who fell and fractured her leg, and failed to use a properly sized lift sling for Resident 24, placing residents at risk for accidents and injury.
F0692: The facility failed to follow the registered dietitians' recommendations for Resident 24 who had significant weight loss, placing the resident at risk for increased weight loss and nutritional deficit.
F0693: The facility failed to provide Resident 41 with appropriate physician ordered fluids before and after administration of nutritional supplement via G-tube, placing the resident at risk for inadequate hydration and a clogged feeding tube.
F0755: The facility failed to provide the physician ordered lidocaine gel or cream to Resident 48 prior to dressing changes, placing the resident at risk for pain and discomfort.
F0761: The facility failed to record refrigerator temperatures in two medication room refrigerators, failed to ensure readable resident name on a Lantus insulin flex pen label, failed to place an open date on Resident 43's Combivent inhaler, and failed to discard an expired bottle of Aspirin, placing residents at risk for use of ineffective medications.
F0921: The facility failed to provide effective housekeeping and maintenance services for one of six halls, Upper Level Wing C, including stained carpets, damaged walls, and soiled furniture.
Report Facts
Residents present: 100
Sampled residents: 21
Weight loss percentage: 18.7
Weight loss percentage: 11.9
Fall risk score: 15
Fall risk score: 45
Weight: 87.4
Weight: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Verified medication labeling and refrigerator temperature issues |
| Administrative Nurse D | Administrative Nurse | Verified wheelchair positioning monitoring and smoking assessment failures |
| Therapy Staff GG | Occupational Therapy Staff | Reported nursing staff had not reported wheelchair positioning problems |
| Certified Nurse Aide O | Certified Nurse Aide | Assisted Resident 24 during transfer with improper lift sling |
| Certified Nurse Aide P | Certified Nurse Aide | Assisted Resident 24 during transfer with improper lift sling |
| Consultant HH | Dietary Consultant | Reported lack of nutritional supplements for Resident 28 |
| Licensed Nurse H | Licensed Nurse | Administered feeding tube nutrition incorrectly for Resident 41 |
| Administrative Nurse E | Administrative Nurse | Verified multiple findings including lift sling training and feeding tube care |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 18, 2018
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2018-08-02.
Findings
All deficiencies have been corrected as of the compliance date of 2018-08-31 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Aug 31, 2018
Visit Reason
This document is a Plan of Correction submitted by Delmar Gardens of Overland Park in response to deficiencies cited in a prior inspection survey.
Findings
The Plan of Correction addresses multiple deficiencies including notification to the State Long-Term Care Ombudsman, accuracy of resident assessments, comprehensive care plans, respiratory care, food service safety, and proper garbage disposal. The facility outlines corrective actions, staff re-education, audits, and ongoing monitoring to ensure compliance.
Deficiencies (7)
F623-B: The community failed to send timely notification to the Office of the State Long-Term Care Ombudsman for residents transferred to the hospital. Notifications were sent and staff re-educated to ensure compliance.
F641-D: The community failed to assure each resident received an accurate and complete assessment reflective of their status. Resident R9's assessment was corrected and audits will be conducted monthly.
F656-D: The community failed to develop and implement comprehensive person-centered care plans meeting residents' preferences and needs. Care plans were updated and audits scheduled.
F657-D: The community failed to ensure timely review and revision of comprehensive care plans to reflect current medical status. Resident R27's care plan was revised and staff re-educated.
F695-E: The community failed to provide respiratory care consistent with professional standards and residents' choices. Equipment labeling and staff education were addressed.
F812-F: The facility failed to store, prepare, distribute, and serve food in accordance with professional safety standards. Immediate corrections and staff in-service were implemented.
F814-F: The community failed to assure proper disposal of garbage and refuse. Dumpsters were closed and staff re-educated on disposal policies.
Inspection Report
Annual Inspection
Census: 82
Deficiencies: 7
Date: Aug 2, 2018
Visit Reason
A Recertification Survey was conducted including investigation of multiple complaint intake numbers in conjunction with the recertification survey.
Complaint Details
Complaint Intake Numbers KS00126865, KS00126855, KS00126567, KS00126301, KS00124418, KS00123236, KS00118187, KS00111230, and KS00096883 were investigated in conjunction with this Recertification Survey.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified in notification of resident transfers to the Ombudsman, accuracy of assessments, comprehensive care planning, respiratory care, food safety, and garbage disposal.
Deficiencies (7)
F623: The facility failed to notify the state Ombudsman of all residents transferred to the hospital since November 2017.
F641: The facility failed to accurately document the comprehensive assessment for one resident, omitting communication difficulties due to limited English proficiency.
F656: The facility failed to develop a comprehensive care plan documenting intravenous antibiotic administration for one resident admitted for IV therapy.
F657: The facility failed to revise the comprehensive care plan to reflect a resident's pancreatic cystic mass diagnosis and related condition changes.
F695: The facility failed to ensure respiratory care equipment was kept clean, labeled, dated, and off the floor for four residents requiring oxygen and nebulizer treatments.
F812: The facility failed to maintain sanitary food preparation conditions, including improper facial hair covers, uncovered equipment, and unsanitary walk-in refrigerator conditions.
F814: The facility failed to properly dispose of garbage, with dumpsters left open and garbage bags exposed, risking sanitation issues.
Report Facts
Survey Census: 82
Sample size: 21
Supplemental Sample: 23
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 2, 2018
Visit Reason
The visit was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a most serious deficiency at level "F", 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 2018-08-31.
Deficiencies (1)
The facility had a level "F" deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure & Certification Enforcement Manager | Contact person for the enforcement decision and plan of correction acceptance. |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Feb 10, 2017
Visit Reason
This Plan of Correction document was submitted in response to deficiencies cited in a prior complaint investigation at Delmar Gardens of Overland Park.
Findings
The facility implemented multiple corrective actions to ensure residents are free from abuse, neglect, and exploitation, including updated care plans, staff re-education, resident interviews, and ongoing monitoring and audits by the Quality Assurance Committee.
Deficiencies (2)
F223-K: The facility updated care plans for residents with behaviors and implemented 1:1 supervision for resident #1 until alternative placement or reassessment. Staff were re-educated on abuse and neglect policies and required to report concerns immediately. Monitoring and audits of resident charts and documentation are ongoing to ensure a safe environment free of abuse.
F225-K: The facility continues to protect residents by reviewing social service notes and auditing charts to document and care plan for inappropriate behaviors. Staff re-education on abuse policies is ongoing, and monitoring of documentation for signs of abuse is conducted weekly with findings reported monthly to the QA Committee.
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 2
Date: Feb 10, 2017
Visit Reason
Partial extended complaint survey conducted due to allegations of abuse involving one resident inappropriately touching multiple opposite gender residents.
Complaint Details
The complaint investigation was triggered by reports that resident #1 inappropriately touched five opposite gender residents multiple times between November 2016 and January 2017. The facility failed to provide adequate monitoring and interventions, and social service documentation was incomplete. The facility abated immediate jeopardy by initiating 1:1 monitoring and revising policies.
Findings
The facility failed to provide an environment free from abuse when one resident with dementia inappropriately touched five opposite gender residents multiple times over several months. The facility lacked timely and effective interventions and documentation to prevent further abuse, placing residents in immediate jeopardy.
Deficiencies (2)
483.12 Free from abuse/involuntary seclusion: The facility failed to prevent resident #1 from inappropriately touching five opposite gender residents repeatedly, placing them in immediate jeopardy.
483.12(a)(3)(4)(c)(1)-(4) Investigate/report allegations/individuals: The facility failed to protect all opposite gender residents from abuse and failed to implement timely and effective interventions to prevent abuse by resident #1.
Report Facts
Census: 97
Residents involved: 6
Dates of incidents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Licensed Staff | Documented multiple observations of resident #1's inappropriate touching and kissing of opposite gender residents. |
| Staff L | Licensed Staff | Documented multiple observations of resident #1's inappropriate touching and implemented redirection and monitoring. |
| Staff H | Licensed Staff | Observed and reported resident #1's inappropriate behaviors and coordinated interventions. |
| Staff O | Direct Care Staff | Witnessed resident #1 inappropriately touching opposite gender residents. |
| Staff Q | Direct Care Staff | Assigned 1:1 monitoring for resident #1 and reported inappropriate behaviors. |
| Staff T | Direct Care Staff | Assigned 1:1 monitoring and intervened to prevent inappropriate behaviors. |
| Staff P | Direct Care Staff | Observed and redirected resident #1's inappropriate touching multiple times. |
| Staff Y | Social Service Staff | Met with resident #1 and families, documented sexual behaviors, and noted lack of protection for other residents. |
| Staff D | Administrative Nursing Staff | Oversaw investigation, instructed 1:1 monitoring, and communicated with state agency. |
| Consultant Staff HH | Psychiatrist Consultant | Evaluated resident #1 and noted sexual behaviors; advised on monitoring and interventions. |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jan 6, 2017
Visit Reason
This is a revisit report completed by a State surveyor to show deficiencies previously reported that have been corrected and the date such corrective action was accomplished.
Findings
The report documents that previously identified deficiencies have been corrected as of the revisit date. Specific corrections are identified by regulation or LSC provision numbers.
Deficiencies (1)
Regulation 28-39-158(a) deficiency was corrected and completed on 2017-01-06.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 6, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies have been corrected as documented in the facility's plan of correction.
Findings
All previously reported deficiencies identified on the CMS-2567 were corrected as of the revisit date. The report confirms completion of corrective actions for multiple regulatory requirements.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jan 6, 2017
Visit Reason
This is a revisit inspection to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiency under regulation 28-39-158(a) was corrected as of 2017-01-06. No other deficiencies or findings are noted.
Deficiencies (1)
Regulation 28-39-158(a) deficiency was corrected as of 2017-01-06.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 6, 2017
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected as documented in the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies were corrected as of the revisit date. The report confirms completion of corrective actions for multiple regulatory requirements.
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 1
Date: Dec 8, 2016
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation for the facility.
Complaint Details
The visit was triggered by complaint investigations #KS00101221 and #KS00099215.
Findings
The facility failed to have a Certified Dietary Manager (CDM) onsite for 4 of 4 days during the survey. Dietary staff who performed supervisory duties were not certified as a CDM.
Deficiencies (1)
KAR 28-39-158(a)(1) The facility failed to have a Certified Dietary Manager (CDM) onsite for 4 of 4 days during the survey. Dietary staff reviewed diets, prepared meals, and directed staff without CDM certification.
Report Facts
Resident census: 89
Days without CDM onsite: 4
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Dec 8, 2016
Visit Reason
This document is a Plan of Correction submitted by Delmar Gardens of Overland Park in response to deficiencies cited during a prior inspection.
Findings
The Plan of Correction addresses multiple deficiencies including 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, staff education, audits, and ongoing monitoring to ensure compliance.
Deficiencies (8)
F280-D: The community will continue to revise and review the care plan of each resident to reflect current needs, including fall interventions and assist rails.
F309-D: The community supports necessary care for residents, including post dialysis assessments and documentation for residents receiving dialysis.
F323-D: The community will provide an environment free from accident hazards, ensuring proper use and monitoring of bed rails and securing housekeeping doors.
F329-E: The community will promote that each resident's drug regimen remains free from unnecessary drugs with appropriate documentation and monitoring.
F371-E: The community will procure, store, prepare, distribute, and serve food under sanitary conditions, including proper labeling, dating, and use of pasteurized eggs.
F428-E: The drug regimen of each resident will be reviewed monthly by a licensed pharmacist with reports of irregularities to the attending physician and Director of Nursing.
F431-E: The community will ensure drugs and biologicals are labeled with expiration dates and stored securely, removing expired or undated medications promptly.
F441-F: The community has an infection prevention and control program with policies and procedures to prevent spread of infections and ensure proper cleaning.
Report Facts
Audit frequency: 5
Audit frequency: 6
Education completion date: Dec 23, 2016
Monitoring duration: 3
Resident monitoring duration: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anastasia Bernard | Administrator | Submitted the Plan of Correction to KDADS. |
| Shirley Boltz | Contact for Plan of Correction assistance. | |
| Irina Strakhova | Modified the Plan of Correction. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 8, 2016
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
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 which was accepted, and the facility was found to be in substantial compliance based on credible allegation of compliance and evidence of correction.
Deficiencies (1)
The facility had an 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the letter regarding the plan of correction acceptance and compliance status. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 8, 2016
Visit Reason
The visit was a Health survey conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
Findings
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 which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and evidence of correction.
Deficiencies (1)
The facility had an 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Sep 29, 2016
Visit Reason
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.
Findings
The report confirms that the identified deficiencies, including one under regulation 483.25(m)(2), were corrected by 08/31/2016 as documented in the revisit.
Deficiencies (1)
Regulation 483.25(m)(2) deficiency was corrected as of 08/31/2016.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 16, 2016
Visit Reason
This document is a Plan of Correction form related to previously reported deficiencies on the CMS-2567 survey report, showing corrections completed and dates of corrective actions.
Findings
The document lists multiple regulatory items with corrections marked as completed on 06/17/2016. It serves as a follow-up to confirm that deficiencies have been addressed.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Aug 2, 2016
Visit Reason
An Abbreviated Survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency at a level of actual harm, F333, "G", which is not immediate jeopardy but requires corrections. Based on this and the facility's history of noncompliance, no opportunity to correct deficiencies before remedies are imposed was given.
Deficiencies (1)
Deficiency F333, "G" level actual harm was cited, requiring corrections as per CMS-2567L. This deficiency is not immediate jeopardy but is serious enough to warrant enforcement remedies.
Report Facts
Denial of payment effective date: Aug 29, 2016
Denial of payment effective date: Aug 29, 2016
Noncompliance history dates: May 19, 2016
Noncompliance history dates: May 27, 2015
Compliance deadline: Feb 2, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | RN, BSN, Complaint Coordinator | Named in relation to complaint coordination and instructions for informal dispute resolution |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 2, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at Delmar Gardens of Overland Park.
Complaint Details
This Plan of Correction is related to a complaint investigation identified as Delmar Gardens complaint 08022016.
Findings
The Plan of Correction addresses medication errors related to the administration and documentation of Duragesic patches. It outlines corrective actions including review of medical records, staff re-education, care plan revisions, and ongoing monitoring.
Deficiencies (1)
F333-G: The facility failed to ensure residents were free of significant medication errors related to Duragesic patch administration and documentation.
Report Facts
Plan of Correction completion date: Aug 31, 2016
Medical records randomly reviewed weekly: 3
Quality Assurance Committee meetings: 3
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 1
Date: Aug 2, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#102499) regarding medication errors at the facility.
Complaint Details
The complaint investigation #102499 found the facility failed to prevent a significant medication error involving a Duragesic patch that caused a resident's hospitalization for narcotic overdose.
Findings
The facility failed to monitor and properly manage the use 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 patch placement, removal, and side effects were noted.
Deficiencies (1)
483.25(m)(2) Residents free of significant medication errors. The facility failed to monitor the placement and side effects of a Duragesic patch for one resident, resulting in narcotic overdose and hospitalization.
Report Facts
Resident census: 92
Sample size: 3
Duration of undocumented monitoring: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff I | Licensed Nurse | Described proper procedures for Duragesic patch placement, removal, and monitoring. |
| Licensed nursing staff J | Licensed Nurse | Described process for placing and removing Duragesic patches and monitoring for overdose symptoms. |
| Consultant staff JJ | Consultant Staff | Commented on effects of multiple Duragesic patches and was unaware of Narcan administration. |
| Administrative nursing staff D | Administrative Nursing Staff | Stated two licensed nurses should be present to remove and replace Duragesic patches. |
| Licensed nursing staff K | Licensed Nurse | Stated two nurses should document removal of Duragesic patches and monitor for overdose symptoms. |
| Direct care staff O | Direct Care Staff | Expressed uncertainty about signs to observe for pain medication overdose. |
| Direct care staff P | Direct Care Staff | Described signs to look for possible pain medication overdose. |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 3
Date: May 19, 2016
Visit Reason
Complaint investigation #98916 was conducted to evaluate the facility's compliance with care planning, services provided, accident prevention, and professional standards.
Complaint Details
The inspection was conducted as a result of complaint investigation #98916.
Findings
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 prevent accidents resulting in a fall and fracture for another resident. Additionally, the facility did not implement fall prevention interventions such as high fall risk tagging for a resident.
Deficiencies (3)
F280: The facility failed to revise care plans for 2 of 3 sampled residents to reflect discontinuation of therapy services.
F281: The facility failed to meet professional standards by not providing a physician-ordered knee brace and documenting it was in place for 1 resident.
F323: The facility failed to prevent accidents for 2 of 3 residents, including a fall resulting in tibia/fibula fracture due to unsafe transfer without a gait belt, and failure to place a high fall risk red tag on a resident's wheelchair.
Report Facts
Resident census: 88
Sample size: 3
Fall dates: 5
Knee unloader brace documentation: 36
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 19, 2016
Visit Reason
An Abbreviated Survey and a Life Safety Code survey were conducted to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The surveys found serious deficiencies at a level of actual harm that is not immediate jeopardy. 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.
Report Facts
Enforcement effective date: Jun 9, 2016
Noncompliance correction deadline: Nov 19, 2016
Civil Money Penalty minimum amount: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named in relation to complaint coordination and informal dispute resolution instructions |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 19, 2016
Visit Reason
The visit was conducted as an Abbreviated Survey and a Life Safety Code survey to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
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, enforcement remedies including denial of payment for new Medicare and Medicaid admissions were imposed.
Report Facts
Denial of payment effective date: Jun 9, 2016
Noncompliance correction deadline: Nov 19, 2016
Civil Money Penalty minimum amount: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as Complaint Coordinator in relation to the survey and enforcement actions |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jan 22, 2016
Visit Reason
This document is a Plan of Correction submitted by Delmar Gardens of Overland Park in response to deficiencies cited in a complaint-related inspection.
Findings
The Plan of Correction addresses deficiencies related to care plan accuracy, restorative therapy provision, and clinical record maintenance. The facility outlines corrective actions including staff education, care plan audits, and ongoing monitoring by leadership and committees.
Deficiencies (3)
F280-D: The community will continue to revise and review the care plan of each resident to reflect current needs, focusing on code status, elopement risk, and fall interventions. Staff education and interdisciplinary monitoring will support accurate documentation and care plan updates.
F309-D: The community supports that each resident receive necessary care to maintain the highest practicable well-being. Restorative therapy orders and programs are reviewed and monitored to ensure they are provided as ordered by the physician.
F514-D: The community will maintain clinical records that are complete, accurate, accessible, and organized. Staff were educated on obtaining physician orders in accordance with residents' code status, and code status reviews will occur on admission and quarterly.
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jan 22, 2016
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the deficiencies previously cited under regulations 483.20(d)(3), 483.10(k)(2), 483.25, and 483.75(l)(1) have been corrected as of the revisit date.
Deficiencies (3)
Regulation 483.20(d)(3), 483.10(k)(2): Previously cited deficiency corrected as of 01/22/2016.
Regulation 483.25: Previously cited deficiency corrected as of 01/22/2016.
Regulation 483.75(l)(1): Previously cited deficiency corrected as of 01/22/2016.
Report Facts
Deficiencies corrected: 3
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 3
Date: Dec 23, 2015
Visit Reason
The inspection was conducted as a complaint investigation based on complaint investigation numbers #88587, 93315, 94157, and 94683.
Complaint Details
The inspection was triggered by complaint investigations #88587, 93315, 94157, and 94683. The complaints involved failure to update care plans, failure to provide ordered restorative services, and inaccurate documentation of code status.
Findings
The facility failed to review and revise care plans for residents related to do not resuscitate status, falls, and elopement risk. The facility also failed to provide restorative/range of motion programs as ordered and failed to accurately document code status in clinical records.
Deficiencies (3)
F 280: The facility failed to review and revise the care plan for resident #2 regarding do not resuscitate status and for resident #7 related to a fall and a Wander Guard bracelet.
F 309: The facility failed to provide restorative/range of motion programs as ordered by the physician for resident #4 and one unsampled resident.
F 514: The facility failed to accurately document the do not resuscitate code status for resident #2 in the clinical record and Physician Order Sheet.
Report Facts
Facility census: 96
Residents sampled: 7
BIMS score: 12
BIMS score: 15
Fall risk assessment scores: 15
Fall risk assessment scores: 18
Fall risk assessment scores: 13
Restorative services days: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Staff V | Interviewed regarding resident #2's do not resuscitate status and form. | |
| Physician Assistant W | Interviewed regarding override of Physician Order Sheet by signed do not resuscitate form. | |
| Licensed Nursing Staff I | Interviewed regarding missing care plan references for resident #7's fall and elopement risk. | |
| Direct Care Staff O | Interviewed regarding restorative program orders and implementation. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Dec 23, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found 'D' level deficiencies indicating 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 the credible allegation of compliance and the plan.
Deficiencies (1)
The facility had 'D' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 23, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All deficiencies previously reported were corrected as of 06/15/2015, as documented by the correction completion dates for each cited regulation.
Report Facts
Deficiency corrections: 12
Inspection Report
Enforcement
Deficiencies: 0
Date: May 27, 2015
Visit Reason
The inspection was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The facility was found not to be in substantial compliance and conditions constituted immediate jeopardy to resident health or safety from April 25, 2015 through May 27, 2015. Enforcement remedies including denial of payment for new Medicare admissions effective June 16, 2015 were imposed.
Report Facts
Denial of payment effective date: Jun 16, 2015
Noncompliance period start: Apr 25, 2015
Noncompliance period end: May 27, 2015
Termination recommendation date: Nov 27, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Heit | Administrator | Named as facility administrator in enforcement report |
| Irina Strakhova | Enforcement Coordinator | Signed enforcement report |
| Jane Weiler | CMS contact for questions regarding enforcement | |
| Joe Ewert | Commissioner | Recipient of informal dispute resolution requests |
Inspection Report
Enforcement
Deficiencies: 0
Date: May 27, 2015
Visit Reason
The inspection was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
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. Enforcement remedies including denial of payment for all new Medicare admissions effective June 16, 2015 were imposed.
Report Facts
Denial of payment effective date: Jun 16, 2015
Non-compliance period start date: Apr 25, 2015
Non-compliance period end date: May 27, 2015
Non-compliance resolution deadline: Nov 27, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Heit | Administrator | Facility administrator named in the report |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement report |
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 11
Date: May 27, 2015
Visit Reason
The inspection was conducted as a Health Resurvey, Extended Health Survey and Complaint Investigation related to allegations of abuse and neglect, falls, pressure ulcers, infection control, and other care concerns.
Complaint Details
The complaint investigation was triggered by allegations of verbal abuse, neglect, falls, pressure ulcers, infection control issues, and failure to follow physician orders. The facility was found to have immediate jeopardy related to abuse and failure to report injuries.
Findings
The facility failed to protect residents from verbal abuse and neglect, failed to investigate and report abuse allegations, failed to provide medically-related social services, 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 by not analyzing falls and implementing interventions, failed to maintain infection control during wound care and room cleaning, and failed to follow physician laboratory orders timely.
Deficiencies (11)
F 223: The facility failed to protect resident #61 from verbal abuse by staff who left the resident on the toilet for approximately 20 minutes and used inappropriate language. The facility failed to properly investigate and report the abuse allegation.
F 225: The facility failed to investigate and report allegations of abuse and injury of unknown source for residents #61 and #94, placing residents in immediate jeopardy.
F 250: The facility failed to provide medically-related social services to resident #61 to address verbal abuse and psychosocial needs.
F 280: The facility failed to update comprehensive care plans for residents #94 and #75 to reflect appropriate fall interventions and changes in dental appliance status.
F 281: The facility failed to update initial care plans for residents #156 and #155 with appropriate fall and pressure relief interventions after changes in condition.
F 309: The facility failed to assess elopement risk for resident #42 and failed to complete neurological assessments for residents #86, #94, and #66 after un-witnessed falls.
F 312: The facility failed to ensure resident #153 received proper oral care, as no toothbrush was available and staff did not assist with oral hygiene.
F 314: The facility failed to develop and implement appropriate interventions to promote healing of pressure ulcers for resident #155, including improper wound care technique and inadequate positioning.
F 441: The facility failed to maintain infection control during wound care for resident #155 and failed to properly clean resident rooms to prevent infection spread.
F 502: The facility failed to follow physician laboratory orders timely for resident #127 and lacked a physician order transcription policy.
F 323: The facility failed to complete root cause analysis and implement timely interventions to prevent falls for resident #94 who sustained a laceration requiring staples and rib fractures.
Report Facts
Resident census: 97
Residents in sample: 24
Ativan dosage: 0.5
Pressure ulcer measurements: 8
Pressure ulcer measurements: 6
Pressure ulcer measurements: 2.4
Pressure ulcer measurements: 2.6
Pressure ulcer measurements: 0.1
Pressure ulcer measurements: 3
Pressure ulcer measurements: 2.1
Pressure ulcer measurements: 2
Pressure ulcer measurements: 1.5
Pressure ulcer measurements: 0.4
Staples: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff R | Direct Care Staff | Named in verbal abuse and neglect incident with resident #61 |
| Staff K | Licensed Nursing Staff | Named in verbal abuse incident reporting and investigation for resident #61 |
| Staff D | Administrative Nursing Staff | Named in verbal abuse incident reporting and investigation for resident #61 |
| Staff E | Administrative Nursing Staff | Witness and involved in verbal abuse incident for resident #61 |
| Staff HH | Social Service Staff | Involved in verbal abuse incident investigation for resident #61 |
| Staff L | Licensed Nursing Staff | Named in improper wound care dressing change for resident #155 |
| Staff O | Direct Care Staff | Named in failure to provide oral care for resident #153 |
| Staff U | Direct Care Staff | Named in failure to provide oral care and wound care for residents |
| Staff N | Licensed Nursing Staff | Named in wound care and care plan failures for resident #155 |
| Staff JJ | Nurse Practitioner | Named in wound care assessment for resident #155 |
| Staff Q | Direct Care Staff | Named in fall prevention for resident #94 |
| Staff J | Licensed Nursing Staff | Named in fall prevention for resident #94 |
| Staff I | Licensed Nursing Staff | Named in fall care for resident #156 |
| Staff T | Direct Care Staff | Named in fall care for resident #156 |
Inspection Report
Plan of Correction
Deficiencies: 11
Date: May 21, 2015
Visit Reason
The document is a Plan of Correction submitted by Delmar Gardens of Overland Park in response to deficiencies cited during a regulatory inspection, including allegations of verbal abuse and injury investigations.
Findings
The facility reported and investigated an allegation of verbal abuse by a direct care staff member and addressed injuries of unknown origin, including rib fractures in a resident. Staff were re-educated on abuse, neglect, exploitation policies, care plan updates, fall prevention, infection control, and lab work compliance. Ongoing monitoring and reporting to the QAPI Committee were established.
Deficiencies (11)
F223-G: The facility must provide an environment free from verbal, sexual, physical, and mental abuse and report and investigate alleged abuse. An allegation of verbal abuse was reported and investigated with staff suspension and re-education.
F225-L: All alleged violations involving mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of resident property must be reported immediately and thoroughly investigated. The facility conducted investigations and reported injuries including rib fractures.
F250-G: The facility must provide medically-related social services to maintain residents' physical, mental, and psychosocial well-being. Staff were re-educated on abuse policies and grievance procedures, with ongoing monitoring.
F280-D: Care plans must be revised and reviewed to reflect residents' current needs. The facility updated care plans for residents with falls and dental appliance changes and re-educated staff on care plan updates.
F281-D: Services must meet professional standards of quality. The facility updated care plans for residents with pressure ulcers and falls and re-educated staff on care plan documentation.
F309-E: Residents must receive necessary care to maintain highest practicable well-being. The facility updated elopement risk assessments and re-educated staff on assessment and documentation.
F312-D: The facility must provide services to maintain good nutrition, grooming, and hygiene. Staff were re-educated on oral care policies and ongoing monitoring was established.
F314-D: Residents must not develop pressure sores unless unavoidable and must receive necessary treatment. The facility updated care plans and re-educated staff on wound care and prevention.
F323-G: The facility must provide an environment free of accident hazards and adequate supervision. The facility investigated rib fractures from a fall and updated fall interventions and care plans.
F441-F: The facility must maintain an Infection Control Program to prevent disease transmission. Staff were re-educated on infection control and housekeeping practices with ongoing monitoring.
F502-D: The facility must provide or obtain laboratory services timely and ensure quality. The facility conducted root cause analysis of missed labs and re-educated staff on following physician orders.
Report Facts
Staff re-education completion date: May 22, 2015
Staff suspension date: May 21, 2015
Resident discharge date: May 22, 2015
X-ray date: May 11, 2015
Lab test date: May 26, 2015
Inspection Report
Follow-Up
Deficiencies: 3
Date: Aug 28, 2014
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
The report confirms that all previously reported deficiencies identified on the CMS-2567 have been corrected as of the revisit date.
Deficiencies (3)
Regulation 483.20(b)(1): Deficiency previously cited has been corrected as of 08/28/2014.
Regulations 483.20(d) and 483.20(k)(1): Deficiencies previously cited have been corrected as of 08/28/2014.
Regulations 483.60(a) and 483.60(b): Deficiencies previously cited have been corrected as of 08/28/2014.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Aug 28, 2014
Visit Reason
This document is a Plan of Correction submitted by Delmar Gardens of Overland Park in response to deficiencies cited during a complaint investigation survey.
Findings
The Plan of Correction addresses incomplete comprehensive assessments, care plan revisions to include hospice services, and pharmaceutical service compliance including medication administration and documentation.
Deficiencies (3)
F272: The community failed to complete comprehensive assessments with all required CAAs for some residents. An audit found 21 of 90 assessments missing parts of CAAs, with plans to complete missing assessments by 08/28/2014.
F279: The community did not consistently use assessment results to develop and revise residents' comprehensive care plans, including integration of hospice services. Care plans for hospice residents were reviewed and revised as needed.
F425: The community did not fully ensure pharmaceutical services and medication administration were completed as ordered. Medication orders and treatment documentation were reviewed and audits planned to ensure compliance.
Report Facts
Assessments reviewed: 90
Assessments missing CAAs: 21
Assessments to be completed: 12
Medical records audited weekly: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Aug 28, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit confirmed that the deficiencies 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.
Deficiencies (3)
Regulation 483.20(b)(1): Previously cited deficiency was corrected by the revisit date.
Regulations 483.20(d) and 483.20(k)(1): Previously cited deficiencies were corrected by the revisit date.
Regulations 483.60(a) and 483.60(b): Previously cited deficiencies were corrected by the revisit date.
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 3
Date: Jul 29, 2014
Visit Reason
The inspection was conducted as a complaint investigation based on complaint investigation numbers #77010 and #75789.
Complaint Details
The citations represent findings from complaint investigations #77010 and #75789.
Findings
The facility failed to accurately and completely assess one of three sampled residents, failed to develop a comprehensive care plan related to hospice services for one resident, and failed to provide pharmaceutical services meeting the needs of two sampled residents.
Deficiencies (3)
F 272: The facility failed to conduct a comprehensive assessment of resident #3, omitting several triggered care areas including delirium, communication, and hospice care.
F 279: The facility failed to develop a comprehensive care plan for resident #3 related to hospice services, lacking integration of hospice care despite documented needs.
F 425: The facility failed to provide pharmaceutical services meeting the needs of residents #1 and #3, with multiple physician-ordered topical medications not administered or documented as given.
Report Facts
Facility census: 109
Residents sampled: 3
Medication non-documentation: 31
Medication non-documentation: 21
Inspection Report
Follow-Up
Deficiencies: 2
Date: May 23, 2014
Visit Reason
This visit was conducted as a post-certification revisit to verify correction of previously cited deficiencies.
Findings
The report confirms that the previously reported deficiencies identified on the CMS-2567 have been corrected as of the revisit date.
Deficiencies (2)
Regulation 483.25 (F0309) deficiency was corrected by 05/23/2014.
Regulation 483.60(a),(b) (F0425) deficiency was corrected by 05/23/2014.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: May 23, 2014
Visit Reason
This document is a Plan of Correction submitted by Delmar Gardens of Overland Park in response to deficiencies cited in a complaint-related inspection.
Findings
The Plan of Correction addresses ensuring residents receive necessary care and services, including pain management and pharmaceutical services, with updated care plans and staff re-education. The facility commits to ongoing audits and reporting to the QAPI Committee.
Deficiencies (2)
F309-D: The community must ensure residents receive necessary care and services to maintain the highest practicable well-being, including updated pain assessments and care plans. Staff were re-educated on pain assessment, documentation, and follow-up with physicians.
F425-D: The community must provide pharmaceutical services that assure accurate acquiring, receiving, dispensing, and administering of drugs. Staff were re-educated on following physician orders and medication transcription, with audits of admission orders.
Report Facts
Medical records audited per week: 10
QAPI Committee reporting frequency: 3
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 2
Date: May 6, 2014
Visit Reason
The inspection was conducted as a complaint investigation (#75125) regarding the facility's failure to provide timely and effective pain management for residents.
Complaint Details
The complaint investigation #75125 focused on pain management deficiencies for three residents, substantiating failures in assessment, documentation, medication administration, and transcription.
Findings
The facility failed to adequately assess and manage pain for three sampled residents, including failure to document pain assessments, monitor responses to pain medication, and properly transcribe medication orders.
Deficiencies (2)
F309: The facility failed to provide timely and effective pain management for three residents, including inadequate pain assessments and failure to monitor responses to pain medication.
F425: The facility failed to provide pharmaceutical services related to pain medication transcription for one resident, including failure to transcribe physician orders for oxycodone.
Report Facts
Resident census: 108
Residents sampled: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff H | Reported no pain assessments documented on MAR for resident #1 | |
| Administrative nursing staff D | Revealed pain assessments should have been completed and documented; noted oxycodone order was not transcribed | |
| Licensed nursing staff J | Revealed pain medication was given but not documented and resident response was not recorded | |
| Licensed nursing staff K | Reported resident's shoulder pain and pain evaluation | |
| Licensed nursing staff L | Revealed nurses should monitor and document pain levels every shift and evaluate effectiveness of pain medication |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Apr 11, 2014
Visit Reason
This document is a Plan of Correction submitted by Delmar Gardens of Overland Park in response to deficiencies cited in a prior inspection report.
Findings
The Plan of Correction addresses pharmaceutical services, ensuring accurate acquiring, receiving, dispensing, and administering of drugs and biologicals. It includes corrective actions such as re-education of nursing staff and auditing medical records to ensure compliance with physician orders.
Deficiencies (2)
F0000 The Plan of Correction is submitted as required under State and Federal law and does not constitute an admission of the accuracy of survey findings or deficiencies cited.
F425-D The Community will continue to provide pharmaceutical services to meet resident needs, including re-education of nursing staff on physician orders and auditing medical records for accuracy.
Report Facts
Medical records audited per week: 10
Plan of Correction completion date: April 11, 2014
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 8, 2014
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
All deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 8, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation numbers were corrected as of the revisit date. The report confirms completion of corrective actions for multiple regulatory citations.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 8, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies have been corrected as indicated in the Plan of Correction.
Findings
All previously reported deficiencies identified on the CMS-2567 Statement of Deficiencies were corrected by the revisit date of 04/08/2014.
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 1
Date: Apr 3, 2014
Visit Reason
The inspection was conducted as a Non-compliance Revisit and Complaint investigation #73315.
Complaint Details
The visit was a complaint investigation and non-compliance revisit related to medication administration errors for resident #8.
Findings
The facility failed to follow physician's orders for one resident (#8) by continuing to administer discontinued medications for nearly two months. The facility also failed to provide a policy regarding medication transcription and failed to transcribe physician's orders to discontinue certain medications.
Deficiencies (1)
483.60(a),(b) Pharmaceutical services were deficient as the facility failed to follow physician's orders for resident #8 by continuing to administer Vitamin C, Vitamin B12, and Simvastatin after they were discontinued. The facility also lacked a policy for transcription of medications.
Report Facts
Resident census: 101
Residents sampled: 15
Duration of medication error: 2
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 3, 2014
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as of the revisit date.
Findings
The report confirms that all deficiencies previously cited on the CMS-2567 have been corrected by the dates listed, with corrections completed by 03/05/2014.
Report Facts
Deficiencies corrected: 15
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 3, 2014
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies were corrected as of March 5, 2014, as documented by the correction completion dates for each regulation cited.
Report Facts
Deficiencies corrected: 15
Inspection Report
Plan of Correction
Deficiencies: 15
Date: Mar 5, 2014
Visit Reason
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.
Findings
The Plan of Correction details multiple corrective actions including promoting resident dignity, supporting resident choice, maintaining a sanitary environment, completing comprehensive assessments, revising care plans, preventing pressure ulcers, ensuring appropriate pharmaceutical services, infection control, and maintaining communication systems.
Deficiencies (15)
F241-D: The community will promote care that maintains or enhances each resident's dignity with respect to individuality. Staff will be re-inserviced on Residents Rights and Dignity and monitored through Resident Council feedback.
F242-D: The community will support residents' rights to choose activities, schedules, and healthcare consistent with their interests and plans of care. Dietary preferences will be assessed and updated regularly.
F253-E: The community will provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.
F272-D: The community will complete comprehensive resident assessments using the Resident Assessment Instrument (RAI) including Care Area Assessments (CAAs) by specified deadlines.
F279-D: The community will develop comprehensive care plans with measurable objectives to meet residents' medical, nursing, and psychosocial needs, updating plans as needed.
F280-E: The community will revise and review care plans to reflect current resident needs, with special emphasis on fall, weight loss, and pressure sore interventions.
F314-G: The community supports prevention and treatment of pressure sores, with ongoing monitoring, documentation, and interventions for at-risk residents.
F315-D: The community will provide appropriate treatment and services to prevent urinary tract infections in incontinent residents and monitor toileting schedules.
F323-E: The community will provide a safe environment free of accident hazards and adequate supervision to prevent falls, with ongoing evaluation and staff re-education.
F325-G: The community will maintain residents' nutritional status and provide therapeutic diets when needed, with monitoring and care plan revisions for weight loss.
F329-E: The community supports drug regimens free from unnecessary drugs, with monitoring of antipsychotic and antianxiety medications and documentation of behaviors.
F425-D: The community will provide pharmaceutical services with licensed pharmacist consultation and ensure transcription and charting of medication orders.
F428-D: The community will ensure monthly pharmacist review of drug regimens and act on irregularities, with monitoring of behavior documentation for residents on psychotropic medications.
F441-D: The community will provide an Infection Control Program to prevent disease transmission, including housekeeping staff training and monitoring of cleaning procedures.
F463-E: The community will maintain resident call systems in rooms, toilets, and bathing facilities, with ongoing monitoring and repair of call light systems.
Report Facts
Weight loss monitoring period: 4
Water temperature: 107.6
Audit frequency: 90
QAPI reporting frequency: 3
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 15
Date: Feb 3, 2014
Visit Reason
Health Resurvey and Complaint Investigation of Delmar Gardens of Overland Park.
Complaint Details
The inspection was a Health Resurvey and Complaint Investigation triggered by complaint KS000063691.
Findings
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.
Deficiencies (15)
F241 dignity and respect: Facility failed to provide care in a dignified manner for a hospice resident and lacked a dignity policy.
F242 self-determination: Facility failed to offer food choices and lacked a policy regarding residents' food preferences.
F253 housekeeping: Facility failed to label towel bars, provide clean linens, and properly store and label personal items in shared bathrooms.
F272 comprehensive assessments: Facility failed to complete comprehensive assessments and care area assessments for two residents.
F279 care plans: Facility failed to develop individualized care plans addressing behaviors and food preferences for three residents.
F280 care plan revisions: Facility failed to revise care plans after falls and for nutritional changes for four residents.
F314 pressure sores: Facility failed to prevent development of pressure ulcers and implement timely interventions for three residents.
F315 urinary incontinence: Facility failed to offer timely toileting for an incontinent resident with cognitive impairment.
F323 accident hazards: Facility failed to prevent injury falls for two residents and failed to maintain safe environment regarding hot water temperature and call light system.
F325 nutrition: Facility failed to prevent significant weight loss and inconsistently monitored meal intake for one resident.
F329 unnecessary drugs: Facility failed to monitor behaviors for two residents, failed to follow pharmacist recommendations for one resident, and lacked indication for antipsychotic use for one resident.
F425 pharmaceutical services: Facility failed to transcribe physician's order to increase Lasix for one resident.
F428 drug regimen review: Facility failed to monitor behaviors for one resident and failed to follow pharmacist's recommendations for another resident.
F441 infection control: Facility failed to follow manufacturer guidelines for disinfectant drying times and lacked policy for drying times.
F463 resident call system: Facility failed to maintain functioning call light system on 3 of 6 hallways.
Report Facts
resident census: 102
weight loss: 38
water temperature: 134.3
water temperature: 126.1
weight: 187
weight: 149
weight loss percentage: 20.32
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Nov 8, 2012
Visit Reason
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.
Findings
The Plan of Correction addresses multiple deficiencies including activity assessments, comprehensive care plan revisions, medication regimen reviews, drug labeling and expiration monitoring, dietetic services oversight, and exit door alarm functionality. The facility requests waivers of time to complete some corrective actions consistent with quarterly review schedules.
Deficiencies (7)
F248-D: The facility will provide ongoing activities programs tailored to residents' interests and abilities, with assessments and care plans updated accordingly.
F280-D: Qualified staff will periodically review and revise comprehensive care plans to reflect residents' current needs, including mobility and oxygen use.
F329-E: The facility will ensure residents' drug regimens are free from unnecessary drugs, with documentation of side effects and black box warnings included in care plans.
F428-E: Licensed pharmacists will review residents' drug regimens monthly, reporting irregularities to physicians and nursing staff for action.
F431-E: Drugs and biologicals will be labeled per professional standards, including expiration dates, with expired medications promptly removed and staff educated on responsibilities.
S0600-C: The facility will maintain dietetic services under a qualified full-time employee, with ongoing consultant dietitian visits and education.
S1174-D: All exit doors will be electronically monitored; a keypad alarm was replaced and staff instructed to report malfunctions promptly.
Report Facts
Requested completion time for corrective actions: 90
Date of Plan of Correction submission: Nov 8, 2012
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 8, 2012
Visit Reason
This is a revisit inspection to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that the deficiencies identified in the prior survey have been corrected as of the revisit date.
Inspection Report
Follow-Up
Deficiencies: 5
Date: Nov 8, 2012
Visit Reason
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.
Findings
The revisit confirmed that all previously cited deficiencies were corrected by the revisit date of 11/08/2012.
Deficiencies (5)
Regulation 483.15(f)(1): Previously cited deficiency corrected as of 11/08/2012.
Regulations 483.20(d)(3) and 483.10(k)(2): Previously cited deficiencies corrected as of 11/08/2012.
Regulation 483.25(l): Previously cited deficiency corrected as of 11/08/2012.
Regulation 483.60(c): Previously cited deficiency corrected as of 11/08/2012.
Regulations 483.60(b), (d), and (e): Previously cited deficiencies corrected as of 11/08/2012.
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Nov 8, 2012
Visit Reason
This visit was a follow-up to verify correction of previously reported deficiencies at Delmar Gardens of Overland Park.
Findings
The report documents that previously cited deficiencies under regulations 28-39-158(a) and 26-40-303 (2)(a)(i)(ii)(iii) were corrected as of the revisit date.
Deficiencies (2)
Regulation 28-39-158(a): Previously cited deficiency was corrected by the revisit date.
Regulation 26-40-303 (2)(a)(i)(ii)(iii): Previously cited deficiency was corrected by the revisit date.
Inspection Report
Follow-Up
Deficiencies: 5
Date: Nov 8, 2012
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that all previously identified deficiencies have been corrected as of the revisit date.
Deficiencies (5)
Regulation 483.15(f)(1): Previously cited deficiency corrected as of 11/08/2012.
Regulations 483.20(d)(3) and 483.10(k)(2): Previously cited deficiencies corrected as of 11/08/2012.
Regulation 483.25(l): Previously cited deficiency corrected as of 11/08/2012.
Regulation 483.60(c): Previously cited deficiency corrected as of 11/08/2012.
Regulations 483.60(b), (d), and (e): Previously cited deficiencies corrected as of 11/08/2012.
Inspection Report
Re-Inspection
Census: 114
Deficiencies: 2
Date: Oct 10, 2012
Visit Reason
The inspection was a health resurvey to assess compliance with dietary services and door monitoring system regulations.
Findings
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 were electronically monitored, specifically the exit door in the therapy room did not alarm when opened.
Deficiencies (2)
28-39-158(a) Dietary services. The facility failed to have a full-time certified dietary manager on site for 5 of 5 days during the survey.
26-40-303 (2)(a)(i)(ii)(iii) Door monitoring system. The facility failed to ensure the exit door in the therapy room was electronically monitored and did not alarm when opened.
Report Facts
Resident census: 114
Inspection Report
Plan of Correction
Deficiencies: 2
Date: May 9, 2012
Visit Reason
This document is a Plan of Correction submitted by Delmar Gardens of Overland Park in response to deficiencies cited in a prior survey.
Findings
The facility was found to have deficiencies related to medication management, specifically regarding documentation and monitoring of residents on anti-hypertensive medications. Residents 1, 2, and 3 no longer reside in the community, so no correction plan is provided for them.
Deficiencies (2)
F0000 The Plan of Correction is submitted as required by law and does not constitute admission of the accuracy of survey findings or deficiencies cited. Changes to policies and procedures are considered remedial measures and inadmissible in legal proceedings.
F329 The facility will promote that each resident's drug regimen is free from unnecessary drugs with adequate indications and monitoring. Education will be provided to licensed nurses and medication aides on proper documentation and monitoring of vital signs for residents on anti-hypertensive medications.
Report Facts
Plan of Correction completion date: May 9, 2012
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 9, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously identified deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the deficiency identified under regulation 483.25(l) was corrected by the revisit date of 05/09/2012. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Regulation 483.25(l) deficiency was corrected as of 05/09/2012.
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 1
Date: Apr 10, 2012
Visit Reason
The inspection was conducted as a complaint investigation identified as #KS55657 regarding medication monitoring and management.
Complaint Details
The complaint investigation #KS55657 found deficiencies related to medication monitoring and management, specifically regarding hypertensive medication parameters and pulse monitoring.
Findings
The facility failed to provide blood pressure (BP) parameters for hypertensive medications and failed to monitor pulse as ordered for three sampled residents. Documentation and monitoring deficiencies were noted in medication administration records and care plans.
Deficiencies (1)
F 329: The facility failed to provide blood pressure parameters for hypertensive medications for three residents and did not monitor pulse per provider orders. Documentation on care plans and medication administration records lacked required parameters and monitoring details.
Report Facts
Resident census: 108
Sample size: 4
Inspection Report
Follow-Up
Deficiencies: 7
Date: Aug 24, 2011
Visit Reason
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.
Findings
All previously reported deficiencies identified by regulation numbers 483.15(e)(1), 483.20(d)(3), 483.10(k)(2), 483.25, 483.25(d), 483.25(h), 483.25(l), and 483.60(b), (d), (e) were corrected as of the revisit date.
Deficiencies (7)
Regulation 483.15(e)(1): Previously cited deficiency corrected as of 08/24/2011.
Regulations 483.20(d)(3) and 483.10(k)(2): Previously cited deficiencies corrected as of 08/24/2011.
Regulation 483.25: Previously cited deficiency corrected as of 08/24/2011.
Regulation 483.25(d): Previously cited deficiency corrected as of 08/24/2011.
Regulation 483.25(h): Previously cited deficiency corrected as of 08/24/2011.
Regulation 483.25(l): Previously cited deficiency corrected as of 08/24/2011.
Regulations 483.60(b), (d), and (e): Previously cited deficiencies corrected as of 08/24/2011.
Inspection Report
Re-Inspection
Census: 105
Deficiencies: 7
Date: Jul 26, 2011
Visit Reason
Health resurvey to assess compliance with previously identified deficiencies and overall regulatory requirements.
Findings
The facility was found deficient in multiple areas including reasonable accommodation of resident needs, care plan revisions, provision of care and services, accident prevention, medication management, and drug labeling and storage.
Deficiencies (7)
F246 Reasonable accommodation of needs was not provided for a resident with wheelchair positioning and mobility issues.
F280 The facility failed to review and revise comprehensive care plans after falls and to update care plans for denture loss.
F309 The facility failed to provide care and services regarding unexplained and undocumented bruising for a resident.
F315 The facility failed to provide adequate incontinence care per policy and resident care plan for a dependent resident.
F323 The facility failed to ensure supervision and use of appropriate assistive devices to prevent falls for a resident.
F329 The facility failed to manage medication regimens properly including lack of diagnoses, monitoring, side effect documentation, and behavior monitoring for residents on psychotropic drugs.
F431 The facility failed to appropriately label and date opened medications and failed to indicate expiration dates on insulin and eye drops.
Report Facts
Resident census: 105
Sample size: 18
Deficiencies cited: 7
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046032 POC WKBM11
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No deficiency details are provided in this document. It serves as a placeholder or record for the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046032 POC UH3N11
Visit Reason
This document is a Plan of Correction submitted in response to a complaint investigation at the facility.
Findings
No specific findings are detailed in this document; it serves as a corrective action plan following a complaint-related inspection.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046032 POC 7FP211
Visit Reason
This document is a Plan of Correction related to a previous inspection event for Delmar Gardens Ov Park.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the Plan of Correction submission.
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