Deficiency Records for Adventhealth Care Center Overland Park
Updated as of April 01, 2024
A list of the most recent deficiencies for Adventhealth Care Center Overland Park. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-29 | 2023-12-20 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-11-15 | 2023-12-20 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-11-15 | 2023-12-20 | N |
| Use approved construction type or materials. | Fire Safety | 2023-11-15 | 2023-12-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-15 | 2023-12-20 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-11-15 | 2023-12-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-11-15 | 2023-12-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-11-15 | 2023-12-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-11-15 | 2023-12-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-15 | 2023-12-20 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-11-15 | 2023-12-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-15 | 2023-12-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-15 | 2023-12-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-15 | 2023-12-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-15 | 2023-12-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-15 | 2023-12-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-11-15 | 2023-12-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-11-15 | 2023-12-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-15 | 2023-12-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-15 | 2023-12-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-15 | 2023-12-20 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-11-15 | 2023-12-20 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-10-19 | 2023-11-28 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-10-19 | 2023-11-28 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-10-19 | 2023-11-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-19 | 2023-11-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-19 | 2023-11-28 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-10-19 | 2023-11-28 | N |
| Post nurse staffing information every day. | Health | 2023-10-19 | 2023-11-28 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-10-19 | 2023-11-28 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-10-19 | 2023-11-28 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-10-19 | 2023-11-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-19 | 2023-11-28 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-10-19 | 2023-11-28 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-10-19 | 2023-11-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-19 | 2023-11-28 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-10-19 | 2023-11-28 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2023-10-19 | 2023-11-28 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-10-19 | 2023-11-28 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-10-19 | 2023-11-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-10-19 | 2023-11-28 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-10-19 | 2023-11-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-07 | 2023-09-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-19 | 2023-07-19 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-06-19 | 2023-07-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-24 | 2022-09-21 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-02-15 | 2022-03-11 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-02-15 | 2022-03-11 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-02-15 | 2022-03-11 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-02-15 | 2022-03-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-02-15 | 2022-03-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-02-15 | 2022-03-11 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-02-15 | 2022-03-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-02-15 | 2022-03-11 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-02-15 | 2022-03-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-15 | 2022-03-11 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-02-15 | 2022-03-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-15 | 2022-03-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-02-15 | 2022-03-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-02-15 | 2022-03-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-02-15 | 2022-03-11 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2022-02-15 | 2022-03-11 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2022-02-15 | 2022-03-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-02-15 | 2022-03-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-15 | 2022-03-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-15 | 2022-03-11 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-02-15 | 2022-03-11 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-01-27 | 2022-03-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-27 | 2022-03-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-27 | 2022-03-02 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-27 | 2022-03-02 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-27 | 2022-03-02 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-01-27 | 2022-03-02 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-01-27 | 2022-03-02 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-01-27 | 2022-03-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-27 | 2022-03-02 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-02-10 | 2020-03-13 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-02-10 | 2020-03-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-10 | 2020-03-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-02-10 | 2020-03-13 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2020-02-10 | 2020-03-13 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-02-10 | 2020-03-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-09 | 2020-02-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-01-09 | 2020-02-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-09 | 2020-02-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-09 | 2020-02-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-01-09 | 2020-02-03 | N |
