Overland Park Post Acute

In the surveyor’s words

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

• Immediate jeopardy, isolatedF726Jan 31, 2022

  The facility identified a census of 112 residents. The sample included three residents with three reviewed for diabetic services. Based on interview, record review, and observation the facility failed to ensure licensed nursing staff possessed the skills and knowledge necessary to follow physician orders, and failed to ensure the licensed nurses possessed knowledge regarding insulin (hormone which regulates blood sugar)administration and monitoring of residents who received fast acting insulin. On 01/17/22 Resident (R)1 admitted to the facility with orders for sliding scale insulin 0-5 units four times daily dependent upon R1's blood glucose levels. […]

• Immediate jeopardy, isolatedF760Jan 31, 2022

  The facility identified a census of 112 residents. The sample included three residents with three reviewed for diabetic services. Based on interview, record review, and observation the facility failed to prevent a significant medication error when the facility failed to ensure Resident (R) 1 received the correct physician ordered sliding scale insulin (hormone which regulates blood sugar). On 01/17/22 R1 admitted to the facility with orders for sliding scale insulin 0-5 units four times daily dependent upon R1's blood glucose levels. The facility inaccurately entered an order to administer 10 milliliters four times daily with no reference to the blood glucose level. Staff then administered 10 units of insulin on eleven occasions when no insulin was required per the correct order. […]

• Immediate jeopardy, isolatedF600Oct 19, 2021

  The facility identified a census of 93 residents. The sample included six residents reviewed for neglect. Based on observation, interview, and record review, the facility failed to ensure Resident (R)1 received the care and services he required when staff left him alone in the shower room for an extended period. Staff left R1, who required staff assistance with activities of daily living, which included showering, alone in a shower chair, naked, wet, and cold at the change of shift. R1, who had bilateral amputations (surgical removal) of the legs, could not self-propel the shower chair out of the stall in order to reach a call light. […]

• Immediate jeopardy, isolatedF689Sep 9, 2021

  The facility reported a census of 93 residents. The sample included three residents reviewed for elopement (when a cognitively impaired resident with little or poor safety awareness exits the facility without staff knowledge). Based on observation, record review, and interview, the facility failed to ensure Resident (R)1 received adequate supervision and appropriate interventions to prevent elopement. R1 was identified as an elopement risk and moved to a locked memory unit on 08/07/21. On 09/07/21 at 03:40 R1 exited the facility via an alarmed fire exit door on the end of the hallway of the locked unit. He went down the stairs and exited the facility via an unalarmed door. Facility staff heard and then canceled the alarm on the fire exit. […]

• Actual harm, isolatedF689Apr 23, 2025

  The facility identified a census of 106 residents. The sample included three residents reviewed for falls and accidents. Based on observation, record review, and interview, the facility failed to investigate, determine causative factors, and implement relevant interventions to prevent further falls for Resident (R) 1, after R1 was found lying face down on the floor, at the bedside, on 11/08/24. Subsequently, R1 had another fall from the bed on 04/10/25, which resulted in a left femur (thigh bone) fracture and placed the resident at risk for further injuries and related pain. […]