Inspection Reports for Homestead of Overland Park Operations LLC
11701 NIEMAN ROAD, KS, 66210-4310
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 31, 2025, found no deficiencies and confirmed the facility was in compliance with all regulations. Prior inspections showed several deficiencies related to improper delegation of nursing duties, meal temperature and documentation issues, tuberculosis testing compliance, and laundry facility conditions. Earlier complaint investigations were mostly unsubstantiated, and no fines or enforcement actions were listed in the available reports. Previous inspections also noted concerns with abuse investigations, emergency preparedness, medication storage, and food safety, but these issues were addressed in subsequent follow-ups. The overall trend indicates improvement, with the facility correcting cited deficiencies in recent inspections.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
5.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% better than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
36 residents
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Mar 31, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-03-06.
Findings
All deficiencies have been corrected as of the compliance date of 2025-03-24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 36
Deficiencies: 4
Mar 6, 2025
Visit Reason
The inspection was a licensure resurvey with attached complaint investigations for multiple complaint numbers conducted on 03/05/2025 and 03/06/2025 at Homestead of Overland Park Operations LLC.
Findings
The facility was found deficient in several areas including improper delegation of nursing duties to Certified Medication Aides, failure to ensure meals were served at proper temperatures and consistently documented, non-compliance with tuberculosis testing guidelines for newly hired employees, and inadequate laundry facility conditions that did not prevent odors or provide proper workflow.
Complaint Details
The inspection included attached complaint investigations for complaint numbers 193590, 191203, 189071, 188960, 183344, and 181507.
Severity Breakdown
E: 3
F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure the Licensed Nurse delegated nursing procedures not included in the Certified Medication Aide curriculum to CMAs as required under the Kansas Nurse Practice Act. | E |
| Failure to ensure meals served to residents in the secured specialty unit were at proper temperature and failure to consistently obtain and document food temperatures prior to serving Assisted Living residents. | E |
| Failure to ensure compliance with tuberculosis guidelines for two newly hired employees due to incomplete or untimely two-step TB testing documentation. | F |
| Failure to store soiled laundry in a manner preventing odors and failure to arrange laundry work area to provide a one-way flow from soiled to clean areas. | E |
Report Facts
Census: 36
Residents in Assisted Living: 23
Residents in secured specialty unit: 13
Food temperature recorded: 116.2
Dates lacking food temperature documentation: 20
Newly hired employees reviewed: 5
Residents in census sample: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CMA F | Certified Medication Aide | Personnel record lacked documentation of delegated nursing procedure of dialing an insulin pen. |
| LN C | Licensed Nurse | Personnel record lacked documentation of required second step tuberculosis test. |
| LN D | Licensed Nurse | Two-step tuberculosis test was not administered within seven days of employment. |
| Dietary staff member B | Confirmed food temperatures were not obtained in the secured specialty unit prior to serving residents. | |
| Operator A | Confirmed issues with laundry room workflow and tuberculosis testing compliance. | |
| LN E | Licensed Nurse | Confirmed lack of documentation for second step TB test for LN C. |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 5, 2025
Visit Reason
The document is a plan of correction addressing findings from a licensure resurvey conducted on 03/05/25 and 03/06/25, which included attached complaint numbers 193590, 191203, 189071, 188960, 183344, and 181507.
Findings
The plan of correction corresponds to deficiencies identified during the licensure resurvey and associated complaint investigations conducted on the specified dates.
Inspection Report
Re-Inspection
Deficiencies: 7
Aug 7, 2023
Visit Reason
This revisit report documents the correction of deficiencies previously cited during an earlier survey, verifying that corrective actions were completed as of the revisit date.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected and completed by the revisit date of 08/07/2023.
Deficiencies (7)
| Description |
|---|
| Deficiency related to regulation 26-41-101 (f) (3) |
| Deficiency related to regulation 26-41-205 (d) (4) |
| Deficiency related to regulation 26-41-103 (c) |
| Deficiency related to regulation 26-41-105 (f) (11) |
| Deficiency related to regulation 26-41-104 (a) |
| Deficiency related to regulation 26-41-104 (d) |
| Deficiency related to regulation 26-41-206 (e) (1) |
Inspection Report
Re-Inspection
Census: 48
Deficiencies: 7
Jul 11, 2023
Visit Reason
The inspection was a resurvey with complaints at Homestead of Overland Park conducted on 07/11/23 and 07/12/23.
Findings
The facility was found deficient in multiple areas including failure to thoroughly investigate abuse allegations, improper delegation of medication administration, lack of dementia staff training, incomplete incident documentation, insufficient staffing for emergency evacuations, failure to conduct emergency preparedness drills and reviews, and unsafe food storage practices.
Complaint Details
The inspection was a resurvey with complaints numbered #181184, #179481, #174286, #174100, #173800, #172528, #172539, #170795, #170509, #170361.
Severity Breakdown
SS=D: 2
SS=E: 2
SS=F: 2
SS=J: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure each incident of potential abuse was thoroughly investigated when bruising was noted on a resident's inner thigh and she presented to the emergency room with pelvic pain. | SS=D |
| Failure to ensure licensed nurse delegated nursing procedures not included in the medication aide curriculum to medication aides under the Kansas nurse practice act when medication aides dialed insulin pens without competency assessment. | SS=E |
| Failure to provide employee orientation and in-service education on treatment and appropriate response to persons exhibiting dementia-related behaviors for 3 of 5 sampled employees. | SS=F |
| Failure to document all incidents, symptoms, and indications of illness or injury including date, time, action taken, and results when a male resident was found in another resident's bed. | SS=D |
| Failure to ensure sufficient staff on night shift to assist all residents requiring assistance in an emergency or disaster, placing residents in immediate jeopardy. | SS=J |
| Failure to ensure disaster and emergency preparedness by not performing quarterly reviews of the emergency management plan with residents and staff and not conducting an annual emergency drill including evacuation to a secure location. | SS=F |
| Failure to ensure all food was stored under safe and sanitary conditions; several food items in the refrigerator were not dated and one pan of fruit was not completely sealed. | SS=E |
Report Facts
Census: 48
Sampled residents: 3
Sampled employees: 5
Residents requiring insulin: 5
Staff on night shift: 2
Residents on locked memory care unit: 16
Residents on assisted living unit: 32
Residents with impaired cognition: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Operator/LN A | Operator/Licensed Nurse | Named in multiple findings including failure to investigate abuse, improper delegation of medication administration, failure to provide dementia training, insufficient staffing, and emergency preparedness failures. |
| Licensed Nurse B | Licensed Nurse | Provided resident roster and nurse's notes; confirmed lack of documentation and assessments. |
| Administrative Staff D | Administrative Staff | Confirmed suspension of alleged perpetrator and lack of completed abuse investigation. |
| Certified Medication Aide H | Certified Medication Aide | Mentioned in relation to lack of competency check offs for insulin pen dialing. |
| Certified Medication Aide I | Certified Medication Aide | Mentioned in relation to lack of competency check offs for insulin pen dialing. |
| Certified Nurse Aide J | Certified Nurse Aide | Mentioned in relation to lack of dementia training. |
| Certified Nurse Aide E | Certified Nurse Aide | Interviewed regarding resident requiring two-person assistance for transfers. |
| Certified Medication Aide/CNA F | Certified Medication Aide/Certified Nurse Aide | Interviewed regarding resident requiring two-person assistance for transfers. |
| Licensed Nurse C | Licensed Nurse | Provided staffing schedules and confirmed lack of emergency preparedness documentation. |
| Dietary Staff G | Dietary Staff | Confirmed food items in refrigerator were not dated. |
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 11, 2023
Visit Reason
The document is a Plan of Correction addressing findings from a resurvey with complaints at the facility conducted on 07/11/23 and 07/12/23.
Findings
The Plan of Correction references multiple complaints (#181184, #179481, #174286, #174100, #173800, #172528, #172539, #170795, #170509, #170361) and the findings from the resurvey conducted on 07/11/23 and 07/12/23.
Complaint Details
The resurvey was conducted in response to multiple complaints as listed in the Plan of Correction.
Inspection Report
Re-Inspection
Deficiencies: 0
Apr 8, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-02-15.
Findings
All deficiencies have been corrected as of the compliance date of 2022-04-04, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 15, 2022
Visit Reason
The document is a plan of correction addressing findings from a licensure resurvey conducted on 2/9/2022, 2/10/2022, 2/14/2022, and 2/15/2022, which included attached complaints numbered 168352, 167470, 161506, and 161345.
Findings
The plan of correction corresponds to citations resulting from the licensure resurvey and associated complaints for the facility conducted over multiple dates in February 2022.
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Feb 9, 2022
Visit Reason
The inspection was conducted as a licensure resurvey with attached complaints numbered 168352, 167470, 161506, and 161345 over multiple dates from 2/9/2022 to 2/15/2022.
Findings
The facility failed to ensure that licensed nurses and certified medication aides stored non-controlled medications and biologicals in locked medication carts, with multiple observations confirming medication carts were unlocked and accessible without certified staff present, potentially affecting all residents.
Complaint Details
The inspection was triggered by complaints #168352, 167470, 161506, and 161345.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure licensed nurses and certified medication aides stored non-controlled medications and biologicals in locked medication carts as required. | SS=F |
Report Facts
Census: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Operator B | Interviewed and observed regarding unlocked medication carts. | |
| Licensed nurse A | Interviewed confirming medication cart bolt was in unlocked position. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Aug 5, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 08/05/2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Follow-Up
Deficiencies: 5
Sep 20, 2018
Visit Reason
This revisit report documents the follow-up inspection to verify that previously reported deficiencies have been corrected and the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies identified by regulation numbers 26-41-202(d), 26-41-203(d), 26-41-205(a)(1), 26-41-205(g)(3), and 26-41-205(h) were corrected as of 09/20/2018.
Deficiencies (5)
| Description |
|---|
| Deficiency related to regulation 26-41-202(d) |
| Deficiency related to regulation 26-41-203(d) |
| Deficiency related to regulation 26-41-205(a)(1) |
| Deficiency related to regulation 26-41-205(g)(3) |
| Deficiency related to regulation 26-41-205(h) |
Inspection Report
Re-Inspection
Census: 44
Deficiencies: 5
Aug 30, 2018
Visit Reason
The inspection was a re-survey for licensure with attached complaints conducted on 8/29/18, 8/30/18, and 9/4/18 at an assisted living/residential care facility.
Findings
The facility was found deficient in multiple areas including failure to review and revise negotiated service agreements annually and after significant changes, improper admission to the memory care unit without appropriate functional capacity screening, failure to assess resident ability for medication self-administration, failure to label over-the-counter medication packages with resident names, and improper storage of medications outside locked compartments.
Severity Breakdown
SS=D: 3
SS=E: 1
SS=F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Administrator failed to ensure review and revision of negotiated service agreement at least once every 365 days and following significant change for resident #830. | SS=D |
| Administrator failed to ensure resident's functional capacity screening indicated benefit from special care services before admission to memory care unit for resident #829. | SS=D |
| Administrator failed to ensure resident could perform medication self-administration safely and accurately without staff assistance for resident #832. | SS=D |
| Administrator failed to ensure licensed nurse or pharmacist placed full resident name on packages of over-the-counter medications for 40 residents. | SS=E |
| Administrator failed to ensure licensed nurses or medication aides stored non-controlled medications and biologicals in locked medication room, cabinet, or medication cart for residents #830 and #833. | SS=F |
Report Facts
Census: 44
Residents receiving medication management: 40
Medication administration instances: 66
OTC medication bottles in locked residential care unit cart: 15
OTC medication bottles/boxes in unlocked assisted living unit carts: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| licensed nurse #B | Licensed Nurse | Confirmed medication self-administration assessment not completed and confirmed resident no longer self-administered medications |
| certified staff #C | Certified Staff | Administered medications to resident #830 and assisted resident #832 with insulin injection |
| certified staff #D | Certified Staff | Left medication unsecured in unlocked cabinet after applying it to resident #833 |
| facility administrator #A | Facility Administrator | Confirmed memory care unit admission criteria and unlocked medication storage observation |
Inspection Report
Re-Inspection
Deficiencies: 2
Sep 13, 2016
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to document the dates such corrective actions were accomplished.
Findings
The report shows that the deficiencies previously cited under regulation numbers 26-41-105(c) and 28-39-255 were corrected as of 09/13/2016. No uncorrected deficiencies were noted.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 26-41-105(c) |
| Deficiency related to regulation 28-39-255 |
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 3
Aug 8, 2016
Visit Reason
The inspection was a licensure re-survey conducted at the assisted living facility to assess compliance with health care services, resident records safeguards, and dietary area sanitation.
Findings
The facility failed to ensure licensed nurse coordination of necessary health care services according to residents' functional capacity screenings and negotiated service agreements, failed to safeguard resident records against unauthorized use, and failed to maintain sanitary conditions in the dietary area.
Severity Breakdown
SS=E: 1
SS=F: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure licensed nurse provides or coordinates necessary health care services in accordance with functional capacity screening and negotiated service agreement for residents #804, #807, and #808. | SS=E |
| Failure to safeguard resident records against unauthorized use; resident charts were accessible in an unlocked nurse office. | SS=F |
| Failure to provide sanitary meal preparation and service in dietary areas; including uncovered trash cans, dirty oven, and greasy stove vents. | SS=F |
Report Facts
Census: 31
Sample residents: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Operator #G | Facility Operator | Interviewed regarding nurse office accessibility and dietary area conditions |
| Licensed staff #J | Licensed Staff | Interviewed regarding resident care and documentation |
| Kitchen staff #H | Kitchen Staff | Interviewed regarding kitchen sanitation and cleaning practices |
Inspection Report
Re-Inspection
Deficiencies: 2
Jul 23, 2014
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to document the dates such corrective actions were accomplished.
Findings
The report shows that the previously cited deficiencies under regulations 26-41-200 (b) and 26-41-206 (e) (1) were corrected as of 07/23/2014.
Deficiencies (2)
| Description |
|---|
| Deficiency under regulation 26-41-200 (b) |
| Deficiency under regulation 26-41-206 (e) (1) |
Inspection Report
Re-Inspection
Census: 28
Deficiencies: 2
Jun 25, 2014
Visit Reason
The inspection was a resurvey conducted on 6-24-14 and 6-25-14 to assess compliance with regulations following previous findings at the assisted living facility.
Findings
The facility was found to have retained a resident requiring physical restraints contrary to regulations, and failed to ensure all food was stored under safe and sanitary conditions, including unlabeled and undated food items in multiple coolers and freezers.
Severity Breakdown
SS=D: 1
SS=F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| The administrator failed to ensure that any resident whose clinical condition requires the use of physical restraints is not retained. | SS=D |
| Facility staff failed to store all food under safe and sanitary conditions, including unlabeled and undated food items in coolers and freezers. | SS=F |
Report Facts
Census: 28
Sample size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| licensed nurse A | Interviewed regarding bed rails on resident #310's bed and assisted in removal | |
| dietary staff C | Identified food items lacking labels/dates during food storage observations | |
| administrator | Responsible for facility compliance and confirmed findings during observations and interviews |
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