Garden Terrace at Overland Park

In the surveyor’s words

From the most serious findings on record at Garden Terrace at Overland Park, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 14, 2026

  Based on observation, record review, and interview, the facility failed to provide adequate supervision and failed to ensure staff responded appropriately to door alarms to prevent the elopement of two cognitively impaired residents. Around 04:30 PM on 05/03/26, Resident (R) 1 and R2 exited the facility without staff knowledge or supervision. Certified Nurse Aide (CNA) M heard a door alarm and reset the alarm without checking to see what triggered the door alarm. At 05:20 PM, the facility learned R1 and R2 were with a community member at a store down the street from the facility. The facility staff did not realize R1 and R2 were out of the facility for approximately 45 minutes. The community member brought R1 and R2 back to the facility in her personal vehicle. […]

• Immediate jeopardy, isolatedF600Nov 18, 2025

  The facility identified a census of 145 residents. The sample included six residents, with six reviewed for abuse and neglect. Based on observation, interview, and record review, the facility failed to ensure cognitively impaired Resident (R) 2 and R3 remained free from resident-to-resident physical abuse by R1. On 09/30/25 at 07:55 AM, Certified Nurse Aide (CNA) N left the facility dining area unsupervised to assist another staff member. When CNA N returned to the dining area, he observed R2 with blood on his face while R1 (who had a history of wandering into resident rooms and behaviors including wanting to fight) stood nearby with blood on his hands. There was blood splashed on the window and table, and pooling on the floor near R2. CNA N asked R1 if he had hit R2, and R1 stated he had. […]

• Immediate jeopardy, isolatedF600Oct 21, 2024

  The facility identified a census of 154 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to ensure cognitively impaired Resident (R) 1 remained free from physical abuse. On 10/09/24 at approximately 08:25 AM, Licensed Nurse (LN) G overheard Certified Nurse Aide (CNA) M tell R1 she could not have any sugar because she was diabetic (a condition when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) and R1 became upset. LN G turned around and observed R1 hit CNA M in the stomach. LN G observed CNA M react to R1 by making a fist and punching R1 in the left upper arm. […]

• Immediate jeopardy, isolatedF689Jul 22, 2024

  The facility identified a census of 156 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to provide adequate supervision to prevent Resident (R) 1, a cognitively impaired resident who had a history of making comments about leaving and was at risk for falls, from eloping from the facility. On 07/15/24 at 01:20 PM, Housekeeping Staff U notified Licensed Nurse (LN) G that R1 made a statement to her that he wanted to go home. LN G retrieved a vital sign machine then went to R1's room to obtain his vital signs and noted he was not in his room. LN G asked other staff members if they had seen R1, but they had not. LN G informed Administrative Nurse D that R1 was missing at 01:21 PM. A Dr. […]

• Immediate jeopardy, isolatedF600Sep 22, 2022

  The facility identified a census of 134 residents. The sample included 11 residents reviewed for abuse. The facility failed to ensure Resident (R)1 remained free from sexual and/or physical abuse. On 09/12/22, the facility transferred cognitively impaired female R1, via ambulance, to an acute care facility due to a change in condition listed as shortness of breath, increased confusion, and respiratory infection. The hospital collected a urine sample on 09/12/22 shortly after R1 arrived and the urine contained sperm. R1 had injuries that the facility had no record or documentation of. R1, who was unable to consent and had not participated in marital sex, showed physical evidence of sexual activity, and had injuries of questionable origin incurred while residing in the facility. […]