Swan Health at Overland Park

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Mar 3, 2025

  The facility identified a census of 29 residents. The sample included three residents reviewed for feeding tubes. Based on record review and interviews, the facility failed to prevent the neglect of Resident (R) 1 when staff did not provide adequate monitoring and timely care and attention to R1's percutaneous endoscopic gastrostomy (PEG tube- feeding tube through the abdominal wall directly into the stomach) site, which became infected, her abdomen became swollen and inflamed, and her right lower abdomen developed darkening, which staff documented as bruising. On [DATE] at 05:34 AM, R1 had a swollen abdomen and a large palpable mass around the PEG tube, with pus noted coming from the site. […]

• Actual harm, isolatedF690Jun 9, 2026

  Based on record review, observations, and interviews, the facility failed to provide the necessary care and services related to indwelling catheter care for Resident (R) 1 when staff removed the catheter, failed to reinsert a catheter and monitor to ensure adequate urine output. Additionally, staff failed to obtain physician involvement. R1 subsequently developed a change in condition and was diagnosed with urine retention, urinary tract infection, and acute kidney injury. Findings included:- R1's Electronic Medical Record (EMR) documented diagnoses of conversion disorder (a mental condition in which a person experiences blindness, paralysis, or other nervous system symptoms that cannot be explained by illness or injury) with seizures (violent involuntary series of contractions of a group… […]

• Actual harm, isolatedF692Sep 18, 2025

  The facility identified a census of 37 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to implement interventions to prevent further weight loss for Resident (R) 1. R1 was admitted to the facility on [DATE] and had a weight loss of 3.85% by 07/02/25 with no documented intervention or response to the loss. R1's weight further declined to a significant loss of 8.85% by 08/01/25 (more than 7.5% in three months) with no documented intervention or response from the facility until 08/14/25. This deficient practice resulted in a total significant weight loss of -11.15% for R1 from 06/06/25 to 08/20/25. […]

• No harm, potential for more than minimal, widespreadF727May 6, 2025

  The facility identified a census of 32 residents. Based on observation, record review, and interview, the facility failed to provide consistent Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week. This placed all the residents who resided in the facility at risk of a lack of assessment and inappropriate care. Findings included: - A review of the facility's submitted Payroll Based Journaling (PBJ - Staffing Data Report) from 04/01/24 through 03/31/25 indicated the facility triggered for no RN coverage on 12 occasions (04/05/24, 4/12/24, 04/19/24, 06/08/24, 07/20/24, 07/21/24, 08/03/24, 08/17/24,11/11/24, 11/17/24, 11/23/24, and 12/09/24). […]

• No harm, potential for more than minimal, widespreadF838May 6, 2025

  The facility identified a census of 32 residents. The sample included 12 residents. Based on interviews and record reviews, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during both day-to-day operations and emergencies. This failure affected all 32 residents residing in the facility. Findings Included: - On 05/05/25, Administrative Staff A provided a Facility Assessment updated 03/01/25. A review of the assessment revealed the following: The assessment identified the required staffing needs per day but failed to identify the specific staffing needs for days, nights, and weekend shifts. […]