9 Reports
Inspection Report — Dec 30, 2025
Annual Inspection CMS
Date: Dec 30, 2025
Visit Reason
The inspection was conducted as an annual survey of the nursing home to assess compliance with regulatory requirements related to resident care and facility operations.
Findings
The facility failed to notify a resident's provider of new or escalating behaviors and failed to provide appropriate dementia care and services. This resulted in ongoing and escalating behaviors including aggression toward other residents and ultimately the resident's transfer to the hospital.
Deficiencies (2)
F 0580: The facility failed to immediately notify the resident, the resident's doctor, and a family member of situations affecting the resident, including new or escalating behaviors.
F 0744: The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, including failure to assess, identify, record, respond to, and reassess specific behaviors and triggers, resulting in escalating aggressive behaviors.
Report Facts
Sample size: 5
Residents reviewed for dementia care: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Consultant GG | Consultant | Named in relation to notification and treatment planning for Resident 1's increased anxiety and agitation |
| Licensed Nurse G | Licensed Nurse | Provided statements regarding notification practices and resident behaviors |
| Licensed Nurse H | Licensed Nurse | Provided statements regarding behavior interventions and notification procedures |
| Administrative Nurse D | Administrative Nurse | Provided statements regarding care plans and behavior interventions |
| CNA M | Certified Nurse Aide | Provided statements regarding resident behaviors and interventions |
Inspection Report — Nov 18, 2025
Complaint Investigation CMS
Date: Nov 18, 2025
Visit Reason
The investigation was conducted due to a complaint regarding resident-to-resident physical abuse involving cognitively impaired residents in the facility.
Complaint Details
The complaint investigation substantiated that resident R1 physically abused residents R2 and R3 on 09/30/25, causing severe injuries including subdural hematomas and facial lacerations. The facility failed to prevent the abuse despite known behavioral issues with R1. Immediate corrective actions were implemented including one-to-one supervision of R1 and staff training.
Findings
The facility failed to protect residents R2 and R3 from physical abuse by resident R1, resulting in serious injuries requiring emergency medical treatment. The incident placed all residents in the immediate area in immediate jeopardy.
Deficiencies (1)
F 0600: The facility failed to protect residents from all types of abuse including physical abuse, resulting in immediate jeopardy to resident health or safety.
Report Facts
Sample size: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA N | Certified Nurse Aide | Witnessed and reported the abuse incident involving residents R1, R2, and R3 |
| CMA R | Certified Medication Aide | Physically removed R1 from R3's room during the abuse incident |
| LN G | Licensed Nurse | Responded to emergency on secured unit and observed injuries to residents |
| Administrative Nurse D | Administrative Nurse | Reported on R1's behavior and facility's immediate corrective actions |
| Consultant GG | Consultant | Provided medical prognosis for resident R3 |
Inspection Report — May 15, 2025
Annual Inspection CMS
Date: May 15, 2025
Visit Reason
Annual inspection of Garden Terrace at Overland Park to assess compliance with regulatory requirements across multiple domains including resident rights, care, medication management, safety, and hospice services.
Findings
The facility was found deficient in multiple areas including failure to provide dignified care, inadequate accommodation of resident preferences, failure to notify physicians of changes, improper medication management including antipsychotic use without proper indication or gradual dose reduction, incomplete care plans, inadequate assistance with activities of daily living, failure to prevent accidents and falls, improper catheter and respiratory care, lack of coordinated hospice care, and failure to obtain required immunizations.
Deficiencies (18)
F550: The facility failed to provide a dignified care environment for several residents, including exposure and lack of privacy during care activities.
F558: The facility failed to reasonably accommodate resident food preferences, including removal of dietary items without consent.
F580: The facility failed to notify a resident's physician of changes related to a head injury, resulting in delayed acute medical treatment.
F582: The facility failed to issue required Medicare Non-Coverage notices to residents discharged with remaining Medicare days, risking impaired decision-making.
F605: The facility failed to ensure antipsychotic medications were used only with appropriate indications and gradual dose reductions, placing residents at risk of unnecessary medication use.
F656: The facility failed to develop comprehensive care plans reflecting resident preferences and respiratory therapy needs, risking impaired care.
F657: The facility failed to revise care plans to include resident-centered functional abilities, risking unmet care needs.
F677: The facility failed to provide necessary assistance with personal hygiene for a resident with dementia, risking poor hygiene and impaired dignity.
F684: The facility failed to follow physician orders to apply thrombo-embolic-deterrent hose daily, risking increased edema and skin complications.
F686: The facility failed to ensure pressure ulcer offloading devices were applied as ordered, increasing risk for pressure ulcers.
F688: The facility failed to ensure application of knee braces as ordered, risking discomfort and decreased range of motion.
F689: The facility failed to provide a safe environment free from accident hazards and adequate supervision, placing residents at risk for falls and injuries.
F690: The facility failed to provide appropriate catheter care including timely emptying of catheter bags, risking urinary tract infections.
F695: The facility failed to ensure physician orders for oxygen therapy were complete and oxygen equipment was stored properly, risking respiratory infection and complications.
F726: The facility failed to ensure staff possessed appropriate competencies to safely provide care, resulting in preventable injuries and delayed treatment.
F744: The facility failed to provide consistent dementia-related care services including managing behaviors and ensuring resident safety and dignity.
F849: The facility failed to ensure coordinated hospice care plans including services, medications, equipment, and frequency of visits, risking inappropriate end-of-life care.
F883: The facility failed to obtain consent or declinations for pneumococcal conjugate vaccine (PCV20) for several residents, risking pneumonia complications.
Report Facts
Sample size: 31
Medication administration opportunities missed: 44
Fall risk score: 15
Laceration size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA Q | Certified Nurse Aide | Named in injury-related accident and termination related to Resident R198 |
| LN K | Licensed Nurse | Notified medical provider of R198's injury and assessed wound |
| Administrative Nurse D | Administrative Nurse | Provided statements on multiple findings including medication management, injury reporting, and care plans |
| LN H | Licensed Nurse | Provided statements on medication administration and resident care |
| CNA P | Certified Nurse Aide | Provided statements on catheter care and respiratory equipment storage |
| LN J | Licensed Nurse | Provided statements on medication administration and hospice care |
Inspection Report — Oct 21, 2024
Complaint Investigation CMS
Date: Oct 21, 2024
Visit Reason
The inspection was conducted following a complaint/allegation of staff-to-resident physical abuse involving Resident 1 (R1).
Complaint Details
The investigation was triggered by an allegation of physical abuse on 10/09/24 involving CNA M and Resident 1. The allegation was substantiated with witness statements, medical documentation, and law enforcement involvement.
Findings
The facility failed to ensure Resident 1 remained free from physical abuse when a Certified Nurse Aide (CNA M) punched R1 in the left upper arm after R1 hit CNA M. The incident caused a bruise and pain requiring medication. The facility took immediate corrective actions including suspension and termination of CNA M, notification of law enforcement, and medical evaluation of R1.
Deficiencies (1)
F 0600: The facility failed to protect Resident 1 from staff-to-resident physical abuse when CNA M struck R1 in the left upper arm causing a bruise and pain. Immediate jeopardy was identified due to this failure.
Report Facts
Residents present: 154
Residents in sample: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Named in physical abuse finding for striking Resident 1 |
| LN G | Licensed Nurse | Witnessed the abuse incident and reported it |
| Administrative Nurse D | Administrative Nurse | Removed CNA M from the facility and managed investigation |
| Consultant GG | Consultant | Provided medical progress note documenting injury to Resident 1 |
| Administrative Staff A | Administrative Staff | Informed about incident and investigation oversight |
Inspection Report — Jul 22, 2024
Complaint Investigation CMS
Date: Jul 22, 2024
Visit Reason
The inspection was conducted following a complaint investigation triggered by an incident where Resident 1 (R1), a cognitively impaired resident, eloped from the facility on 07/15/24 without staff knowledge or alarm notification.
Complaint Details
The investigation was initiated due to a complaint about Resident 1 eloping from the facility on 07/15/24. The complaint was substantiated as the resident was found outside the facility without staff knowledge or alarm notification, placing the resident at immediate risk.
Findings
The facility failed to provide adequate supervision to prevent R1 from eloping. The stairwell door alarm was turned off, allowing R1 to exit unnoticed and be found outside in unsafe conditions. This placed R1 in immediate jeopardy. The facility implemented corrective actions including one-on-one supervision, care plan updates, staff education, and alarm system audits.
Deficiencies (1)
F 0689: The facility failed to ensure the nursing home area was free from accident hazards and did not provide adequate supervision to prevent Resident 1 from eloping. The stairwell door alarm was turned off, allowing the resident to exit unnoticed and be found outside in unsafe conditions.
Report Facts
Temperature outside: 92
Temperature outside: 93
BIMS score: 11
Haldol dosage: 1
Lorazepam dosage: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Notified about Resident 1's elopement and searched for the resident |
| Administrative Nurse D | Administrative Nurse | Notified of Resident 1 missing, searched and found Resident 1 outside, coordinated response |
| Housekeeping Staff U | Reported Resident 1's statement about wanting to go home and alerted nursing staff | |
| Social Services X | Social Services Staff | Assisted in searching for Resident 1 and bringing him back inside |
| CMA R | Certified Medication Aide | Assisted in searching for Resident 1 and reported not seeing him |
| Administrative Staff A | Administrative Staff | Assisted in bringing Resident 1 back inside and reported on staff expectations |
Inspection Report — May 28, 2024
Complaint Investigation CMS
Date: May 28, 2024
Visit Reason
The inspection was conducted following a complaint investigation related to the facility's failure to provide appropriate dementia care and services for a resident with dementia, specifically regarding staff utilization of resident-specific interventions for behaviors.
Complaint Details
The complaint investigation involved an incident on 05/23/24 where Activity AA was observed smacking Resident 1's hands and grabbing her arm, which was against care plan interventions. Witness statements from Consultant GG and CNA N documented the event and subsequent investigation. Activity AA was suspended pending investigation. The resident exhibited agitation related to her husband leaving and dementia-related behaviors.
Findings
The facility failed to provide adequate dementia care for Resident 1 by not ensuring staff used resident-specific behavioral interventions. An incident was documented where a staff member improperly handled the resident, leading to agitation and potential harm, despite care plans addressing these behaviors.
Deficiencies (1)
F0744: The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia by not ensuring staff utilized resident-specific interventions for behaviors. This failure affected the resident's ability to maintain the highest practicable level of physical, mental, and psychosocial well-being.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Consultant GG | Witnessed and reported the incident involving Resident 1 and Activity AA | |
| Activity AA | Unit Coordinator | Staff member involved in the incident with Resident 1 |
| CNA N | Certified Nurse Aide | Assisted Resident 1 and provided witness statement regarding the incident |
| CNA M | Certified Nurse Aide | Provided information on Resident 1's behaviors and care |
| Licensed Nurse G | Licensed Nurse | Provided information on care plans and resident behaviors |
| Administrative Nurse D | Administrative Nurse | Discussed staff expectations regarding care plans and resident behaviors |
| Activity Z | Activity Personnel | Provided information on staff access to care plans and knowledge of interventions |
Inspection Report — May 6, 2024
Complaint Investigation CMS
Date: May 6, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to ensure Resident 1 received necessary assistive care and services with activities of daily living (ADL) to maintain her highest practicable ability and promote independence.
Complaint Details
The investigation was complaint-driven, focusing on Resident 1's care related to ADLs and weight-bearing restrictions. The complaint was substantiated as staff failed to follow non-weight-bearing orders and did not properly document or communicate these restrictions.
Findings
The facility failed to ensure Resident 1 received appropriate assistance with ADLs and proper weight-bearing status was not consistently documented or followed, placing the resident at risk for injury, pain, and decreased ability to perform ADLs. Staff walked the resident despite non-weight-bearing orders, and communication of weight-bearing restrictions was inadequate.
Deficiencies (1)
F 0676: The facility failed to ensure Resident 1 received necessary assistive care and services with ADLs to maintain her highest practicable ability and promote independence. This placed Resident 1 at risk for injury, pain, and decreased ability to perform ADLs.
Report Facts
Residents Affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| M | Certified Nurse Aide (CNA) | Stated Resident 1's weight-bearing status was communicated by word of mouth and described walking Resident 1 to the bathroom |
| G | Licensed Nurse (LN) | Stated Resident 1 had no weight-bearing or ADL restrictions and required assistance of one staff member |
| D | Administrative Nurse | Confirmed lack of weight-bearing orders and staff failure to maintain non-weight-bearing status for Resident 1 |
Inspection Report — Sep 12, 2023
Routine CMS
Date: Sep 12, 2023
Visit Reason
Routine inspection of Garden Terrace at Overland Park nursing home to assess compliance with regulatory requirements including resident care, safety, medication management, infection control, and staff training.
Findings
The facility failed to ensure dignified care, appropriate use of wheelchair foot pedals, timely transfer notifications, adequate assistance with activities of daily living, proper application of physician-ordered treatments, pain management, dementia care, medication regimen review, infection control, and staff training. Several residents were at risk for decreased psychosocial wellbeing, preventable accidents, infections, and inadequate care.
Deficiencies (17)
F 0550: The facility failed to ensure residents R14, R30, and R109 received dignified care during meals and social interactions, placing them at risk for decreased self-esteem and psychosocial wellbeing.
F 0558: The facility failed to provide foot pedals on wheelchairs for residents R17 and R45, risking preventable accidents during transport.
F 0623: The facility failed to provide timely written notification of hospital transfers to resident R3 or their legal representative, risking miscommunication and missed healthcare opportunities.
F 0625: The facility failed to provide bed hold notice for hospitalized resident R115, risking uninformed choices.
F 0677: The facility failed to provide required assistance and special adaptive equipment to resident R41 during meals, risking weight loss and physical decline.
F 0684: The facility failed to provide appropriate care and treatments for residents R41 and R45, including preventing aspiration and ensuring application of physician-ordered tubigrips, risking respiratory illness and skin integrity issues.
F 0688: The facility failed to implement a range of motion program for resident R143 and failed to ensure R45's hand splint was applied, risking loss of mobility and contractures.
F 0689: The facility failed to secure the soiled utility room containing hazardous materials and failed to follow fall prevention interventions for resident R145, risking preventable accidents and injuries.
F 0690: The facility failed to provide appropriate catheter care for resident R115, including hand hygiene, anchoring catheter tubing, and maintaining drainage bag position, risking catheter-related complications.
F 0697: The facility failed to recognize, assess, and treat pain for resident R94, risking ongoing pain and diminished quality of life.
F 0730: The facility failed to ensure three of five CNAs completed the required 12 hours of annual in-service education, risking inadequate care.
F 0744: The facility failed to provide adequate dementia care and supervision for residents R17, R41, and R45, risking impaired quality of life and psychosocial wellbeing.
F 0756: The facility failed to ensure the consultant pharmacist identified inappropriate use and lack of physician rationale for antipsychotic medication Seroquel for resident R133, risking unnecessary medication and side effects.
F 0758: The facility failed to ensure gradual dose reductions and non-pharmacological interventions for psychotropic medication use for resident R133, risking unnecessary medication and side effects.
F 0812: The facility failed to ensure proper hair covering and hand hygiene by food service staff, risking food contamination and foodborne illness.
F 0880: The facility failed to ensure appropriate hand hygiene and proper use of personal protective equipment during catheter care and other activities, risking infectious disease transmission.
F 0947: The facility failed to provide required dementia education to CNA PP, risking decreased quality of life and inadequate dementia care.
Report Facts
In-service hours: 6.78
In-service hours: 8.9
In-service hours: 6.53
Pain level: 4
Pain level: 4
Medication administration count: 2
Medication administration count: 5
Medication administration count: 6
Medication administration count: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse H | Licensed Nurse | Named in catheter care and infection control deficiencies for resident R115 |
| Certified Nurse Aide P | Certified Nurse Aide | Named in meal assistance and resident monitoring deficiencies |
| Administrative Nurse D | Administrative Nurse | Named in multiple findings including resident care, infection control, and medication management |
| Licensed Nurse K | Licensed Nurse | Named in wheelchair safety and resident care deficiencies |
| Certified Nurse Aide N | Certified Nurse Aide | Named in catheter care and infection control deficiencies |
| Licensed Nurse L | Licensed Nurse | Named in resident care and medication management deficiencies |
| Certified Nurse Aide O | Certified Nurse Aide | Named in wheelchair safety and fall prevention deficiencies |
| Certified Nurse Aide M | Certified Nurse Aide | Named in range of motion and pain management deficiencies |
| Licensed Nurse G | Licensed Nurse | Named in infection control and resident care deficiencies |
| Licensed Nurse J | Licensed Nurse | Named in medication management deficiencies |
| Certified Nurse Aide PP | Certified Nurse Aide | Named in staff training deficiency |
Inspection Report — Mar 7, 2022
Complaint Investigation CMS
Date: Mar 7, 2022
Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify physicians of abnormal resident conditions, failure to provide required Medicare notices, failure to provide proper food safety equipment, and failure to coordinate hospice care.
Complaint Details
The investigation was complaint-driven, focusing on issues related to medication notification failures, Medicare notice provision failures, food safety equipment deficiencies, and hospice care coordination failures.
Findings
The facility failed to notify the physician of low blood pressures for one resident, failed to provide required Medicare Non-Coverage notices to three residents, failed to provide a backflow prevention device for the kitchen ice machine, and failed to coordinate hospice care for one resident.
Deficiencies (4)
F 0580: The facility failed to notify the physician of low blood pressures for Resident 57, placing the resident at risk for continued low blood pressures and adverse medication side effects.
F 0582: The facility failed to provide required Medicare Non-Coverage notices (CMS forms 10123 and 10055) to Residents 13, 14, and 214 or their representatives, placing them at risk to make uninformed decisions about continuation of skilled care.
F 0812: The facility failed to provide a backflow device or two-inch air gap for the drainage system of the kitchen ice machine, placing 111 residents at risk for contaminated ice.
F 0849: The facility failed to ensure a coordinated hospice care plan was developed and available for Resident 41, placing the resident at risk for inappropriate end of life care.
Report Facts
Medication holds: 27
Residents reviewed: 23
Residents reviewed for Beneficiary Notices: 3
Viewing
Loading inspection reports...
