Inspection Reports for Delmar Gardens of Overland Park
12100 W. 109TH STREET, OVERLAND PARK, KS, 66210-1200
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 18, 2018, found no deficiencies and confirmed that all prior issues had been corrected. Earlier inspections showed recurring deficiencies mainly related to resident assessments, care planning, respiratory care, food safety, and proper garbage disposal. Complaint investigations were generally unsubstantiated in recent years, though earlier investigations substantiated issues including medication errors, falls, abuse allegations, and infection control concerns. Enforcement actions included a denial of payment for new Medicare admissions in 2015 due to immediate jeopardy findings, but no fines or license suspensions were listed in the available reports. The facility’s inspection history shows improvement over time, with more recent surveys indicating compliance and correction of previously cited deficiencies.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
28.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
378% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
82 residents
Based on a August 2018 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 18, 2018
Visit Reason
An offsite revisit survey was conducted on 09/18/2018 to verify correction of all previous deficiencies cited on 08/02/2018.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 08/31/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
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 report.
Findings
The Plan of Correction addresses multiple deficiencies including notification to the State Long-Term Care Ombudsman, accuracy of resident assessments, development and implementation of person-centered care plans, respiratory care standards, food service safety, and proper garbage disposal. The facility outlines corrective actions, staff re-education, audits, and ongoing monitoring to ensure compliance.
Deficiencies (7)
Failure to send timely notification to the Office of the State Long-Term Care Ombudsman for residents transferred to the hospital.
Inaccurate or incomplete resident assessments not reflective of resident status.
Lack of comprehensive person-centered care plans meeting resident preferences and needs.
Untimely review and revision of comprehensive care plans to reflect current medical status.
Respiratory care and services not consistently meeting professional standards, including improper labeling and storage of oxygen equipment.
Food service safety issues including improper cleaning of slicer and walk-in refrigerator, and improper use of beard restraints.
Improper disposal of garbage and refuse, including uncovered dumpsters.
Report Facts
Audit frequency: 10
Audit frequency: 4
Notification date: Aug 3, 2018
Plan completion dates: Aug 30, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance |
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 this 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 areas including notice requirements before transfer/discharge, accuracy of assessments, comprehensive care planning, respiratory care, food safety, and garbage disposal.
Deficiencies (7)
Failed to notify the state Ombudsman of all residents transferred to the hospital since November 2017.
Failed to correctly document the comprehensive assessment for one resident, specifically communication ability.
Failed to develop a comprehensive care plan documenting intravenous antibiotic administration for one resident.
Failed to revise the comprehensive care plan to accurately describe a resident's current medical status related to a pancreatic cystic mass.
Failed to ensure respiratory care equipment was kept clean, labeled, dated, and off the floor for four residents.
Failed to store, prepare, and serve food under sanitary conditions including improper facial hair covers, uncovered equipment, and unsanitary walk-in refrigerator conditions.
Failed to properly dispose of garbage; dumpsters were left open with garbage and boxes exposed.
Report Facts
Sample size: 21
Supplemental sample: 23
Oxygen tubing change frequency: 7
Pancreatic cystic mass size: 1.6
Pancreatic cystic mass size: 1.8
Pancreatic cystic mass size: 1.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Interviewed regarding failure to notify Ombudsman of resident transfers. | |
| Administrator | Confirmed failure to notify Ombudsman of resident transfers. | |
| Director of Nursing (DON) | Interviewed regarding care plan deficiencies and respiratory care. | |
| Minimum Data Set Coordinator (MDSC) | Interviewed regarding care plan deficiencies. | |
| Registered Nurse (RN) | Interviewed regarding care plan revision and coordination. | |
| Dietary Manager | Interviewed and observed regarding improper facial hair covers and kitchen sanitation. | |
| Dishwasher 1 | Observed wearing improper facial hair cover. | |
| Cook 1 | Observed wearing improper facial hair cover. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 2, 2018
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be a 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 08/31/2018.
Deficiencies (1)
Most serious deficiencies found to be a 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure & Certification Enforcement Manager | Named as contact person regarding the inspection and plan of correction. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 6, 2017
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 had been corrected.
Findings
All previously cited deficiencies were corrected as of the revisit date, with completion dates documented for each deficiency.
Report Facts
Deficiencies corrected: 8
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jan 6, 2017
Visit Reason
This report is a revisit conducted by a State surveyor to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiency with regulation 28-39-158(a) was corrected as of 01/06/2017. No other deficiencies or findings are noted.
Deficiencies (1)
Deficiency related to regulation 28-39-158(a) previously reported and now corrected
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 identified by #KS00101221 and #KS00099215.
Complaint Details
The visit was triggered by a complaint investigation as indicated by the Health Resurvey and Complaint Investigation numbers #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 was not a CDM was performing duties including reviewing diets, preparing meals, and directing dietary staff.
Deficiencies (1)
Facility failed to have a Certified Dietary Manager (CDM) onsite for 4 of 4 days of the survey.
Report Facts
Census: 89
Days without CDM onsite: 4
Inspection Report
Plan of Correction
Deficiencies: 7
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 in a prior inspection report dated December 8, 2016.
Findings
The Plan of Correction addresses multiple deficiencies related to care plan revisions, fall interventions, dialysis care, accident hazard prevention, medication management, food safety, infection control, and drug regimen monitoring. The facility outlines corrective actions including staff education, audits, monitoring, and reporting to Quality Assurance committees to ensure compliance and resident safety.
Deficiencies (7)
Care plans were not consistently revised to reflect current resident needs including fall interventions and assist rails.
Post dialysis assessments and documentation were not consistently completed for residents receiving dialysis.
Environmental safety issues including unsecured housekeeping doors and improper use of bed rails or positioning devices.
Inadequate documentation and monitoring of residents' drug regimens, including targeted behaviors and medication effectiveness.
Food safety concerns including undated, unlabeled, improperly closed, and expired food items.
Expired and undated medications and treatment items found in medication carts and rooms.
Infection prevention and control practices needed reinforcement, including cleaning procedures and product usage.
Report Facts
Audit frequency: 5
Education completion date: Dec 23, 2016
Quality Assurance reporting: 3
Food monitoring duration: 72
Environmental audits: 6
Cleaning audits: 6
Dietary Services Manager exam period: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | Listed as contact person for Plan of Correction assistance. |
| Anastasia Bernard | Administrator | Submitted the Plan of Correction to KDADS. |
| Director of Nursing | Named in multiple corrective actions including dialysis care, medication monitoring, and reporting. | |
| Assistant Director of Nursing | ADON | Responsible for care plan revisions and audits. |
| RN Nurse Educator | Responsible for staff education and re-education on multiple topics including fall interventions, dialysis, medication management, and infection control. | |
| Environmental Services Director | Responsible for monitoring housekeeping door security, cleaning audits, and staff education. | |
| Dining Services Director | DSD | Responsible for food safety education and monitoring. |
| Dietary Services Manager | DSM | Completed assignments and test related to dietetic services. |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Dec 8, 2016
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be an "F" level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on credible allegation of compliance and evidence of correction effective January 6, 2017.
Deficiencies (1)
"F" level deficiency, widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and referenced in relation to survey findings and compliance |
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 previously cited deficiency related to regulation 483.25(m)(2) was corrected by 08/31/2016. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Deficiency related to regulation 483.25(m)(2)
Report Facts
Deficiency correction completion date: Aug 31, 2016
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Aug 16, 2016
Visit Reason
This document is a Plan of Correction form submitted to show deficiencies previously reported on the CMS-2567 survey report have been corrected and the date such corrective action was accomplished.
Findings
The document lists multiple deficiencies identified by regulation numbers and indicates that corrections for these deficiencies were completed by 06/17/2016.
Deficiencies (3)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.20(k)(3)(i)
Deficiency related to regulation 483.25(h)
Report Facts
Correction completion date: Corrections completed on 06/17/2016 for listed deficiencies
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise Dawson | Surveyor | Signature of surveyor on Plan of Correction form |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Aug 2, 2016
Visit Reason
An Abbreviated Survey was conducted on August 2, 2016, by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency at a level of actual harm, F333, 'G', which is not immediate jeopardy but requires corrections. Due to the facility's history of noncompliance from previous surveys in May 2016 and May 2015, no opportunity to correct deficiencies before remedies are imposed was granted.
Deficiencies (1)
Deficiency at level of actual harm, F333, 'G'
Report Facts
Denial of payment effective date: Aug 29, 2016
Substantial compliance deadline: Feb 2, 2017
Civil Money Penalty minimum amount: 5000
Days to request Informal Dispute Resolution: 10
Days to request hearing: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | RN, BSN, Complaint Coordinator | Named in relation to instructions for Informal Dispute Resolution and contact for questions |
| Lisa Hauptman | Contact person at CMS for questions regarding the matter | |
| Codi Thurness | Commissioner | Recipient of written requests for Informal Dispute Resolution |
| Darla McCloskey | Branch Manager | Authorized the letter |
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 ensure residents were free of significant medication errors, specifically related to improper management of a Duragesic patch causing narcotic overdose and hospitalization of resident #1.
Findings
The facility failed to monitor the placement and side effects of a Duragesic (fentanyl) patch for one resident, resulting in a significant medication error that caused narcotic overdose and hospitalization. Documentation and monitoring deficiencies related to the patch placement, removal, and witnessing by nursing staff were identified.
Deficiencies (1)
Failed to monitor placement and side effects of Duragesic patch resulting in resident hospitalization for narcotic overdose.
Report Facts
Census: 92
Sample size: 3
Duragesic patch dosage: 12
Duration of monitoring gap: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff O | Interviewed and stated uncertainty about signs to observe for pain medication overdose | |
| Licensed nursing staff I | Interviewed and described proper procedures for Duragesic patch placement, removal, and documentation | |
| Direct care staff P | Interviewed and described signs to look for in pain medication overdose | |
| Licensed nursing staff J | Interviewed and described process for placing and removing Duragesic patch and monitoring for overdose | |
| Consultant staff JJ | Interviewed and stated multiple patches would cause decreased consciousness and rapid vital sign decline | |
| Administrative nursing staff D | Interviewed and stated two licensed nurses should be present to remove and replace Duragesic patch | |
| Licensed nursing staff K | Interviewed and stated two nurses should document removal and monitor resident for overdose symptoms |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 19, 2016
Visit Reason
An Abbreviated Survey and a Life Safety Code survey were conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
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, the facility will not be given an opportunity to correct deficiencies before enforcement remedies are imposed.
Deficiencies (1)
Deficiencies found at a level of actual harm that is not immediate jeopardy requiring corrections
Report Facts
Enforcement effective date: Jun 9, 2016
Noncompliance deadline: Nov 19, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | RN, BSN, Complaint Coordinator | Named in relation to complaint coordination and instructions for dispute resolution |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 19, 2016
Visit Reason
An Abbreviated Survey and a Life Safety Code survey were conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The surveys found the most serious deficiencies at a level of actual harm that is not immediate jeopardy, requiring corrections. Due to the facility's history of noncompliance on the May 27, 2015 annual survey, no opportunity to correct deficiencies before remedies are imposed was granted.
Deficiencies (1)
Deficiencies found at a level of actual harm that is not immediate jeopardy
Report Facts
Denial of payment effective date: Jun 9, 2016
Noncompliance deadline: Nov 19, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | RN, BSN, Complaint Coordinator | Named in relation to complaint coordination and instructions for dispute resolution |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 3
Date: May 19, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#98916) to evaluate the facility's compliance with care planning, services provided, and fall prevention interventions.
Complaint Details
The visit was triggered by 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 implement fall prevention interventions resulting in a resident fall with tibia/fibula fractures and failure to place a high fall risk tag on another resident's wheelchair.
Deficiencies (3)
Failed to revise care plans for 2 of 3 sampled residents regarding discontinuation of therapy services.
Failed to meet professional standards by not providing a physician ordered knee brace and documenting it was in place when it was not.
Failed to provide care and services to prevent accidents for 2 of 3 residents sampled for falls, including a fall resulting in tibia/fibula fracture during an inappropriate transfer and failure to place a high fall risk tag.
Report Facts
Census: 88
Sample size: 3
Fall dates: 5
Dates therapy ordered: 30
Dates therapy ordered: 2
Dates of fall risk assessments: 4
Dates of fall risk assessments: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff E | Acknowledged failure to update care plans and discussed knee brace documentation and expectations | |
| Direct care staff C | Observed assisting Resident #2 with transfers and toileting | |
| Therapy staff L | Stated resident refused knee brace and never had it in the facility | |
| Direct care staff A | Witnessed fall of Resident #1 during transfer without gait belt | |
| Licensed nursing staff G | Stated staff should use gait belt with all transfers and was unaware of knee brace for Resident #3 |
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 survey.
Complaint Details
This Plan of Correction is in response to a complaint survey identified by Complaint ID 122315.
Findings
The Plan of Correction addresses multiple deficiencies related to care plan accuracy, restorative program compliance, and clinical record maintenance. The facility outlines corrective actions including staff education, care plan audits, and ongoing monitoring and reporting to the Quality Assurance and Improvement Committee.
Deficiencies (3)
Care plans not reflective of current resident needs, including specifics of code status, elopement risk, and fall interventions.
Failure to provide restorative programs as ordered by the physician.
Clinical records not maintained in accordance with accepted professional standards; incomplete or inaccurate documentation.
Report Facts
Plan of Correction completion date: Jan 22, 2016
Quality Assurance and Improvement Committee reporting frequency: 3
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jan 22, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit report shows that the deficiencies previously cited under regulations 483.20(d)(3), 483.10(k)(2), 483.25, and 483.75(l)(1) were corrected as of the revisit date.
Deficiencies (3)
Deficiency related to regulations 483.20(d)(3) and 483.10(k)(2)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.75(l)(1)
Report Facts
Deficiencies corrected: 3
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 the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'D' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan of correction.
Deficiencies (1)
Deficiencies cited at 'D' level constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as the contact person for the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 4
Date: Dec 23, 2015
Visit Reason
The inspection was conducted as a complaint investigation covering multiple complaint investigation numbers (#88587, 93315, 94157, and 94683).
Complaint Details
The inspection findings represent the results of complaint investigations #88587, 93315, 94157, and 94683.
Findings
The facility failed to review and revise care plans for residents related to do not resuscitate status, falls, and elopement risk. Additionally, the facility failed to provide restorative/range of motion programs as ordered and failed to accurately document code status for a resident.
Deficiencies (4)
Failed to review and revise the care plan for resident #4 related to do not resuscitate status.
Failed to review and revise the care plan for resident #7 related to a fall and a Wander Guard bracelet.
Failed to provide restorative/range of motion program as ordered by the physician for resident #4 and one unsampled resident.
Failed to accurately document the code status for resident #2.
Report Facts
Residents sampled: 7
Facility census: 96
Fall risk assessment scores: 15
Fall risk assessment scores: 18
Fall risk assessment scores: 13
Restorative program days ordered: 3
Restorative program days received: 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 do not resuscitate form overriding Physician Order Sheet. | |
| Licensed nursing staff I | Interviewed regarding inability to find care plan reference related to resident #7's fall and elopement risk. | |
| Direct care staff O | Interviewed regarding restorative program procedures. |
Inspection Report
Follow-Up
Deficiencies: 11
Date: Jul 23, 2015
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies had been corrected.
Findings
The report documents that all previously cited deficiencies were corrected by 06/15/2015, with no uncorrected deficiencies remaining as of the revisit date.
Deficiencies (11)
Deficiency related to regulation 483.13(b), 483.13(c)(1)(i)
Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2) - (4)
Deficiency related to regulation 483.15(g)(1)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.20(k)(3)(i)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(a)(3)
Deficiency related to regulation 483.25(c)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.65
Deficiency related to regulation 483.75(j)(1)
Report Facts
Deficiencies corrected: 11
Inspection Report
Enforcement
Deficiencies: 2
Date: May 27, 2015
Visit Reason
A Health survey was conducted by the Kansas Department for Aging & Disability Services to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
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. Deficiencies were severe enough to warrant denial of payment for all new Medicare admissions effective June 16, 2015.
Deficiencies (2)
Noncompliance with F225 CFR 01-483,25(c) constituting immediate jeopardy to resident health or safety
Substandard Quality of Care with noncompliance at F225 "L", CFR 01-483,13(c)
Report Facts
Denial of payment effective date: Jun 16, 2015
Compliance deadline: Nov 27, 2015
Civil Money Penalty minimum: 5000
IDR request timeframe: 10
Hearing request timeframe: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Heit | Administrator | Facility administrator named in the report |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
| Jane Weiler | CMS Survey & Certification Branch | Contact person for questions regarding the matter |
| Joe Ewert | Commissioner, Survey, Certification and Credentialing Commission | Recipient of Informal Dispute Resolution requests |
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 9
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, and other compliance issues.
Complaint Details
The complaint investigation included allegations of verbal abuse and neglect of resident #61, failure to investigate and report abuse, falls with injury and lack of appropriate interventions, inadequate wound care, infection control issues, and failure to provide timely laboratory services.
Findings
The facility failed to protect residents from abuse, failed to investigate and report allegations of abuse, failed to provide medically-related social services to address abuse, failed to update care plans for falls and dental appliance changes, failed to complete neurological assessments after un-witnessed falls, failed to provide proper oral care, failed to implement appropriate wound care interventions, failed to prevent accidents and falls, failed to properly clean resident rooms to prevent infection, and failed to provide timely laboratory services.
Deficiencies (9)
Failed to protect resident #61 from verbal abuse and neglect by staff, failed to investigate and report the abuse allegation.
Failed to provide medically-related social services to resident #61 to address abuse and psychosocial needs.
Failed to update comprehensive care plans for residents #94 and #75 for falls and dental appliance changes.
Failed to complete neurological assessments for residents #86, #94, and #66 after un-witnessed falls.
Failed to ensure resident #153 received proper oral care.
Failed to develop and implement appropriate interventions to promote healing of pressure ulcers for resident #155.
Failed to ensure resident environment was free of accident hazards and failed to provide adequate supervision and interventions to prevent falls for resident #94 who sustained a laceration and rib fractures.
Failed to properly perform wound care dressing changes with appropriate hand hygiene and glove use, and failed to properly clean resident rooms to prevent infection.
Failed to provide or obtain laboratory services in a timely manner for resident #127 and failed to have a physician's order transcription policy.
Report Facts
Residents in sample: 24
Residents census: 97
Deficiency severity SS=G: 3
Deficiency severity SS=D: 4
Deficiency severity SS=E: 1
Deficiency severity SS=F: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff R | Direct Care Staff | Named in verbal abuse and neglect allegation involving resident #61. |
| Staff K | Licensed Nursing Staff | Involved in reporting and responding to abuse allegation for resident #61. |
| Staff D | Administrative Nursing Staff | Involved in abuse investigation and follow-up for resident #61. |
| Staff E | Administrative Nursing Staff | Witness and involved in abuse incident for resident #61. |
| Staff HH | Social Service Staff | Involved in abuse incident discussion for resident #61. |
| Staff A | Administrative Nursing Staff | Expected grievance and investigation for abuse incident for resident #61. |
| Staff L | Licensed Nursing Staff | Performed wound care dressing change with improper hand hygiene. |
| Staff O | Direct Care Staff | Observed not assisting resident #153 with oral care. |
| Staff U | Direct Care Staff | Unaware of resident #153 wounds and care plan. |
| Staff N | Licensed Nursing Staff | Reported wound care interventions for resident #153. |
| Staff JJ | Nurse Practitioner | Observed wounds of resident #155 and acknowledged lack of documentation. |
| Staff Q | Direct Care Staff | Reported resident #94 was independent with ambulation. |
| Staff J | Licensed Staff | Reported resident #94 was independent with ambulation and educated on call light use. |
| Staff D | Administrative Staff | Updated care plan for resident #94 after fall. |
| Staff Z | Housekeeping Staff | Failed to properly disinfect resident room suspected of scabies. |
| Staff AA | Housekeeping Staff | Failed to properly clean resident room surfaces. |
| Staff Y | Housekeeping Staff | Reported cleaning procedures and glove use. |
| Staff D | Administrative Nursing Staff | Acknowledged failure to complete laboratory order for resident #127. |
Inspection Report
Plan of Correction
Deficiencies: 6
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 prior inspection, including allegations of verbal abuse and injury investigations.
Findings
The Plan of Correction details the facility's actions to address allegations of verbal abuse, injury investigations including rib fractures, staff re-education on abuse and neglect policies, resident safety monitoring, care plan updates, infection control, and laboratory service compliance.
Deficiencies (6)
Failure to prevent verbal abuse and properly investigate allegations of abuse.
Failure to report and communicate injuries of unknown origin, including rib fractures.
Inadequate staff training and re-education on abuse, neglect, exploitation, and complaint grievance procedures.
Failure to update and monitor resident care plans reflecting current needs and interventions.
Inadequate infection control practices and monitoring.
Failure to ensure timely and accurate laboratory services and follow-up.
Report Facts
Date of staff suspension: May 21, 2015
Date of rib fracture x-ray: May 11, 2015
Date of staff re-education completion: May 22, 2015
Number of residents randomly interviewed monthly: 4
Number of medical records audited weekly: 6
Number of random housekeeping audits weekly: 4
Number of random housekeeping observations weekly: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Heit | Administrator | Administrator who initiated investigations and submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Aug 28, 2014
Visit Reason
This is a post-certification revisit to verify that previously identified deficiencies have been corrected as shown on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report documents that deficiencies previously cited under regulations 483.20(b)(1), 483.20(d), 483.20(k)(1), and 483.60(a),(b) were corrected as of the revisit date.
Deficiencies (3)
Deficiency under regulation 483.20(b)(1)
Deficiency under regulations 483.20(d) and 483.20(k)(1)
Deficiency under regulations 483.60(a) and 483.60(b)
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Aug 28, 2014
Visit Reason
This Plan of Correction document was submitted in response to deficiencies cited during a complaint investigation survey at Delmar Gardens of Overland Park.
Complaint Details
This Plan of Correction is related to a complaint investigation survey as indicated by the reference to the complaint and audit of assessments following the complaint.
Findings
The Plan of Correction addresses deficiencies related to incomplete comprehensive assessments (CAAs), integration of hospice services into care plans, and pharmaceutical services including medication administration and documentation.
Deficiencies (3)
Incomplete comprehensive assessments with missing CAAs for some residents.
Failure to use assessment results to develop, review, and revise residents' comprehensive plans of care including hospice services.
Pharmaceutical services not fully compliant with physician orders, including medication administration and documentation.
Report Facts
Assessments reviewed: 90
Assessments missing CAAs: 21
Residents discharged: 5
Residents needing new assessments: 12
Medical records audited weekly: 5
Plan of Correction completion date: Aug 28, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Alan Ware | Submitted the Plan of Correction to KDADS |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jul 29, 2014
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'D' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.
Deficiencies (1)
Deficiencies cited at 'D' level constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
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 ensure accurate and comprehensive assessments and care plans for residents, specifically related to hospice services for resident #3. Additionally, the facility failed to provide pharmaceutical services meeting the needs of residents #1 and #3, with multiple instances of medication administration not documented or refused.
Deficiencies (3)
Failed to conduct a comprehensive and accurate assessment of resident #3's functional capacity and care needs.
Failed to develop a comprehensive care plan for resident #3 related to hospice services.
Failed to provide pharmaceutical services to meet the needs of residents #1 and #3, including failure to administer prescribed topical medications as ordered.
Report Facts
Residents sampled: 3
Facility census: 109
Medication non-documentation: 31
Medication non-documentation: 21
Medication refusal: 6
Inspection Report
Follow-Up
Deficiencies: 2
Date: May 23, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report documents that deficiencies identified under regulations 483.25 and 483.60(a),(b) were corrected as of the revisit date, May 23, 2014.
Deficiencies (2)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.60(a),(b)
Report Facts
Deficiencies corrected: 2
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 survey.
Findings
The Plan of Correction addresses deficiencies related to pain assessment and management, medication administration, and physician order transcription. The facility outlines corrective actions including staff re-education, auditing medical records, and ongoing monitoring by the Director of Nursing and QAPI Committee.
Deficiencies (2)
Failure to ensure residents receive necessary care and services to maintain highest practicable well-being, specifically related to pain assessment and management.
Failure to provide pharmaceutical services ensuring accurate acquiring, receiving, dispensing, and administering of drugs and biologicals.
Report Facts
Medical records audited per week: 10
QAPI Committee reporting frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| Alanware | Administrator | Submitted the Plan of Correction to KDADS. |
| Irina Strakhova | Added the Plan of Correction on 05/19/2014. | |
| Mary Jane Kennedy | Modified the Plan of Correction on 05/20/2014. |
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 issues for 3 residents, substantiating failures in pain assessment, documentation, medication administration, and transcription of physician orders.
Findings
The facility failed to adequately assess and manage pain for 3 sampled residents, including failure to document pain assessments, monitor response to pain medication, and properly transcribe physician orders for pain medication.
Deficiencies (2)
Failure to provide timely and effective pain management for 3 of 3 residents (#1, #2, and #3).
Failure to provide pharmaceutical services related to pain medication transcription for 1 of 3 residents (#1).
Report Facts
Residents sampled for pain: 3
Facility census: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff D | Administrative Nursing Staff | Revealed pain assessments should have been documented and that oxycodone medication order was not transcribed |
| Licensed nursing staff H | Licensed Nursing Staff | Revealed no pain assessments documented on MAR since resident returned from hospital |
| Licensed nursing staff J | Licensed Nursing Staff | Revealed pain medication was given but not documented on MAR and resident response was not documented |
| Licensed nursing staff K | Licensed Nursing Staff | Reported resident's shoulder pain to doctor and confirmed daily pain evaluation |
| Licensed nursing staff L | Licensed Nursing Staff | Revealed nurses should monitor and document pain level every shift and evaluate effectiveness of pain medication |
| Licensed nursing staff I | Licensed Nursing Staff | Notified resident was in distress and on hospice services |
Inspection Report
Follow-Up
Deficiencies: 15
Date: Apr 8, 2014
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
The report confirms that all previously identified deficiencies listed with their regulation numbers have been corrected as of the revisit date.
Deficiencies (15)
Deficiency identified under regulation 483.15(a)
Deficiency identified under regulation 483.15(b)
Deficiency identified under regulation 483.15(h)(2)
Deficiency identified under regulation 483.20(b)(1)
Deficiency identified under regulation 483.20(d), 483.20(k)(1)
Deficiency identified under regulation 483.20(d)(3), 483.10(k)(2)
Deficiency identified under regulation 483.25(c)
Deficiency identified under regulation 483.25(d)
Deficiency identified under regulation 483.25(h)
Deficiency identified under regulation 483.25(i)
Deficiency identified under regulation 483.25(l)
Deficiency identified under regulation 483.60(a),(b)
Deficiency identified under regulation 483.60(c)
Deficiency identified under regulation 483.65
Deficiency identified under regulation 483.70(f)
Inspection Report
Follow-Up
Deficiencies: 15
Date: Apr 8, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that all previously cited deficiencies listed with their regulation numbers were corrected as of the revisit date.
Deficiencies (15)
Deficiency identified under regulation 483.15(a)
Deficiency identified under regulation 483.15(b)
Deficiency identified under regulation 483.15(h)(2)
Deficiency identified under regulation 483.20(b)(1)
Deficiency identified under regulation 483.20(d), 483.20(k)(1)
Deficiency identified under regulation 483.20(d)(3), 483.10(k)(2)
Deficiency identified under regulation 483.25(c)
Deficiency identified under regulation 483.25(d)
Deficiency identified under regulation 483.25(h)
Deficiency identified under regulation 483.25(i)
Deficiency identified under regulation 483.25(l)
Deficiency identified under regulation 483.60(a),(b)
Deficiency identified under regulation 483.60(c)
Deficiency identified under regulation 483.65
Deficiency identified under regulation 483.70(f)
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 to assess compliance with pharmaceutical service procedures.
Complaint Details
The visit was triggered by a complaint investigation #73315 and was a Non-compliance Revisit.
Findings
The facility failed to follow physician's orders for one resident (#8) by continuing to administer discontinued medications (Vitamin C, Vitamin B12, and Simvastatin) for nearly two months after the physician ordered their discontinuation. The facility also lacked a policy regarding transcription of medication orders.
Deficiencies (1)
Failure to follow physician's orders for resident #8 by continuing to administer discontinued medications.
Report Facts
Census: 101
Residents sampled: 15
Duration of medication error: 2
Inspection Report
Follow-Up
Deficiencies: 14
Date: Apr 3, 2014
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected by 03/05/2014 as verified during this revisit.
Deficiencies (14)
Deficiency related to regulation 483.15(a)
Deficiency related to regulation 483.15(b)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulation 483.20(b)(1)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25(c)
Deficiency related to regulation 483.25(d)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.25(i)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.60(c)
Deficiency related to regulation 483.65
Deficiency related to regulation 483.70(f)
Report Facts
Deficiencies corrected: 14
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 3, 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.
Findings
The Plan of Correction addresses pharmaceutical service deficiencies, including accurate acquiring, receiving, dispensing, and administering of medications. It outlines corrective actions such as re-education of nursing staff, auditing medical records, and reporting to the QAPI Committee.
Deficiencies (1)
Inaccurate completion and transcription of physician medication orders.
Report Facts
Medical records audited per week: 10
Re-in servicing completion date: Apr 11, 2014
Medication discontinuation date: Mar 28, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Alanware | Administrator | Submitted the Plan of Correction |
| Irina Strakhova | Added and modified the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 16
Date: Feb 12, 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 re-inservicing staff on residents' rights, dignity, care plans, dietary preferences, infection control, medication monitoring, fall prevention, pressure ulcer prevention, and maintenance of a safe environment. It includes timelines for completion and ongoing monitoring through the QAPI Committee.
Deficiencies (16)
Failure to maintain residents' dignity and respect.
Failure to support residents' rights to choose activities, schedules, and healthcare.
Failure to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior.
Failure to properly label and store residents' personal items and provide clean linens.
Failure to complete comprehensive resident assessments including Care Area Assessments (CAAs).
Failure to develop comprehensive care plans addressing medical, nursing, mental, and psychosocial needs.
Failure to revise and review care plans reflective of current resident needs.
Failure to prevent pressure sores and provide necessary treatment.
Failure to provide appropriate treatment and services to incontinent residents to prevent urinary tract infections.
Failure to provide a safe environment free of accident hazards and adequate supervision to prevent accidents.
Failure to maintain residents' nutritional status and provide therapeutic diets when needed.
Failure to ensure residents' drug regimens are free from unnecessary drugs and properly monitored.
Failure to provide pharmaceutical services including licensed pharmacist consultation.
Failure to ensure drug regimen reviews by pharmacist and reporting irregularities.
Failure to provide an effective Infection Control Program.
Failure to maintain resident call light systems in working order.
Report Facts
Plan of Correction completion dates: Mar 3, 2014
Plan of Correction completion dates: Feb 28, 2014
Plan of Correction completion dates: Apr 30, 2014
Water temperature: 107.6
Weekly weights monitoring: 4
Random care plan audits: 4
Medical record audits: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alanware | Administrator | Submitted the Plan of Correction to KDADS |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 13
Date: Feb 3, 2014
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation to assess compliance with regulatory requirements.
Complaint Details
The inspection included a complaint investigation as indicated by the initial comments and the nature of the deficiencies found related to resident care and facility compliance.
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 (13)
Failed to provide care in a dignified manner for a resident on hospice.
Failed to offer food choices and failed to provide a policy regarding residents' food choices.
Failed to label towel bars, provide clean linens, and properly store and label personal use items in shared bathrooms.
Failed to complete comprehensive assessments and Care Area Assessments (CAAs) for residents.
Failed to develop comprehensive individualized care plans for residents including those with behaviors and catheter use.
Failed to revise care plans after falls and changes in resident condition.
Failed to prevent development of pressure ulcers and failed to implement timely interventions after identification of skin redness.
Failed to offer timely toileting for an incontinent resident.
Failed to prevent injury falls and maintain a safe environment free of accident hazards including hot water temperature control.
Failed to assess and provide timely interventions to prevent significant weight loss.
Failed to monitor behaviors and follow pharmacist recommendations for residents on psychotropic medications.
Failed to provide appropriate infection control techniques including adherence to disinfectant drying times.
Failed to maintain a functioning resident call light system on multiple hallways.
Report Facts
Resident census: 102
Weight loss: 38
Water temperature: 134.3
Water temperature: 126.1
Pressure ulcer size: 1.7
Pressure ulcer size: 0.7
Medication dosage: 40
Medication dosage: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative licensed staff E | Administrative Licensed Nurse | Acknowledged missed Lasix order and care plan updates. |
| Licensed nurse L | Licensed Nurse | Performed wound care dressing change for resident #99. |
| Maintenance manager II | Maintenance Manager | Acknowledged water temperature issues and lack of policy. |
| Administrative nursing staff D | Administrative Nursing Staff | Discussed care plan revisions and call light system expectations. |
| Consultant pharmacist JJ | Consultant Pharmacist | Reported concerns regarding inconsistent behavior and bowel monitoring documentation. |
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Nov 8, 2012
Visit Reason
This revisit report documents the correction of previously cited deficiencies at Delmar Gardens of Overland Park, verifying that corrective actions were completed as of the revisit date.
Findings
The report confirms that the deficiencies previously reported under regulation numbers 28-39-158(a) and 26-40-303 (2)(a)(i)(ii)(iii) were corrected by the revisit date of 11/08/2012.
Deficiencies (2)
Deficiency under regulation 28-39-158(a)
Deficiency under regulation 26-40-303 (2)(a)(i)(ii)(iii)
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 as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that all previously identified deficiencies have been corrected as of the revisit date, with corrections completed on 11/08/2012 for multiple regulatory items.
Deficiencies (5)
Deficiency related to regulation 483.15(f)(1)
Deficiency related to regulations 483.20(d)(3) and 483.10(k)(2)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.60(c)
Deficiency related to regulations 483.60(b), (d), (e)
Report Facts
Deficiencies corrected: 5
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Oct 11, 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 details multiple areas for improvement including activity assessments, comprehensive care plan updates, medication regimen reviews, drug labeling and expiration monitoring, dietetic services oversight, and exit door safety compliance. The facility requests waivers of time to complete some corrective actions within 90 days.
Deficiencies (7)
Inadequate activity assessments and care plans for residents.
Comprehensive care plans not reflecting current resident needs and status.
Medication regimens not fully reviewed for unnecessary drugs and side effects.
Drug regimen reviews by pharmacist not fully documented or timely.
Expired medications found in treatment carts and medication rooms.
Dietetic services supervisor not fully certified as required by state.
Exit doors not electronically monitored properly due to malfunctioning keypad alarm.
Report Facts
Days for waiver request: 90
Years of experience: 17
Completion date: Jan 7, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katie Allen | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
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, specifically the therapy room exit door, were electronically monitored and functioning properly.
Deficiencies (2)
Facility failed to have a full-time certified dietary manager on site for 5 of 5 days.
Facility failed to ensure the exit door in the therapy room was electronically monitored and functioning properly.
Report Facts
Census: 114
Days without certified dietary manager: 5
Days exit door not monitored: 1
Date last door check: Sep 16, 2012
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 9, 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 report confirms that the deficiency identified under regulation 483.25(l) with ID prefix F0329 was corrected on 05/09/2012.
Deficiencies (1)
Deficiency under regulation 483.25(l) previously cited
Report Facts
Deficiency correction date: May 9, 2012
Inspection Report
Plan of Correction
Deficiencies: 1
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, addressing medication regimen monitoring and documentation.
Findings
The Plan of Correction outlines corrective actions including in-service education for nursing staff, audits of medication documentation, and ongoing review of residents' medication regimens to ensure appropriate monitoring and reporting of vital signs related to anti-hypertensive medications.
Deficiencies (1)
Failure to ensure each resident's drug regimen was free from unnecessary drugs with adequate indications and monitoring.
Report Facts
Plan of Correction completion date: May 9, 2012
In-service education completion date: May 4, 2012
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 3
Date: Apr 10, 2012
Visit Reason
The inspection was conducted as a complaint investigation (#KS55657) focusing on the facility's compliance with drug regimen requirements, specifically monitoring and parameters for hypertensive medications.
Complaint Details
Complaint investigation #KS55657 focused on drug regimen and medication monitoring compliance.
Findings
The facility failed to provide adequate blood pressure (BP) parameters for hypertensive medications and failed to monitor pulse as ordered for three of four sampled residents. Documentation and monitoring deficiencies were noted in admission orders, care plans, and medication administration records.
Deficiencies (3)
Failed to provide BP parameters for hypertensive medications for residents #1, #2, and #3.
Failed to monitor pulse for hypertensive medication Coreg per provider's order for resident #2.
Failed to monitor effectiveness and provide BP parameters for hypertensive medication Diltiazem for resident #3.
Report Facts
Census: 108
Sample size: 4
Inspection Report
Follow-Up
Deficiencies: 7
Date: Aug 24, 2011
Visit Reason
This is a post-certification revisit conducted to verify that previously identified deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All deficiencies previously cited in the initial survey have been corrected as of the revisit date, with corrections completed for multiple regulatory requirements.
Deficiencies (7)
Deficiency related to regulation 483.15(e)(1)
Deficiency related to regulations 483.20(d)(3) and 483.10(k)(2)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(d)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.25(l)
Deficiency related to regulations 483.60(b), (d), (e)
Report Facts
Deficiencies corrected: 7
Inspection Report
Re-Inspection
Census: 105
Deficiencies: 7
Date: Jul 26, 2011
Visit Reason
Health Resurvey to assess compliance with regulatory requirements and to verify correction of previous deficiencies.
Findings
The facility was found deficient in multiple areas including failure to provide reasonable accommodation of resident needs, failure to revise care plans after falls, inadequate care for urinary incontinence, failure to prevent accidents due to improper use of assistive devices, failure to manage medication regimens properly, and failure to label and date medications appropriately.
Deficiencies (7)
Failure to provide reasonable accommodation of needs for resident #55 related to wheelchair positioning and mobility.
Failure to review and revise comprehensive care plans for residents #48 and #37 regarding falls and denture loss.
Failure to provide care and services regarding unexplained and undocumented bruising for resident #6.
Failure to provide adequate incontinence care for resident #48.
Failure to ensure supervision to prevent accidents for resident #112 who fell due to improper transfer technique.
Failure to manage medication regimen properly for 5 residents (#176, #178, #55, #45, #112) including lack of diagnoses, monitoring, and side effect documentation.
Failure to appropriately label and date opened medications including insulin and eye drops.
Report Facts
Deficiencies cited: 7
Resident census: 105
Sample size: 18
BIMS score: 9
BIMS score: 2
BIMS score: 3
BIMS score: 15
BIMS score: 7
Fall risk score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| licensed nurse A | Licensed Nurse | Named in multiple interviews related to medication monitoring, care plan revisions, and resident care findings |
| licensed nurse B | Licensed Nurse | Interviewed regarding resident wheelchair fall and behavior observations |
| licensed nurse C | Licensed Nurse | Interviewed regarding bowel movement monitoring and medication side effects |
| licensed staff D | Direct Care Staff | Involved in resident transfer leading to fall and medication room interview |
| licensed staff E | Licensed Staff | Interviewed regarding medication labeling and expiration |
| direct care staff A | Direct Care Staff | Interviewed and observed providing resident care including incontinence care and wheelchair assistance |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: N046032 POC 5LZ611
Visit Reason
This Plan of Correction is submitted in response to deficiencies cited in the Delmar Gardens complaint inspection dated 08/02/2016, addressing medication errors related to Duragesic patch administration and documentation.
Complaint Details
This Plan of Correction is in response to a complaint investigation related to medication errors involving Duragesic patches.
Findings
The facility identified issues with medication errors involving Duragesic patches, including documentation of site placement, monitoring, removal, and destruction. The Plan of Correction outlines steps for review, staff re-education, care plan revisions, and ongoing monitoring to ensure compliance and prevent significant medication errors.
Deficiencies (1)
Significant medication errors related to Duragesic patch administration and documentation
Report Facts
Date of Plan of Correction completion: Aug 31, 2016
Number of medical records randomly reviewed weekly: 3
Number of Quality Assurance and Performance Improvement Committee meetings for reporting: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Deniemendola | Assistant Administrator | Submitted the Plan of Correction |
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