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Deficiency Records for Delmar Gardens of Overland Park
A list of the most recent deficiencies for Delmar Gardens of Overland Park. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Delmar Gardens of 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? |
|---|---|---|---|---|
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-04-10 | 2024-05-24 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-04-10 | 2024-05-23 | 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 | 2024-04-10 | 2024-05-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-04-10 | 2024-05-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-10 | 2024-05-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-04-10 | 2024-05-23 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-04-10 | 2024-05-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-04-10 | 2024-05-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-03-13 | 2024-04-26 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-03-13 | 2024-04-26 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-03-13 | 2024-04-26 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-03-13 | 2024-04-26 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2024-03-13 | 2024-04-26 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-03-13 | 2024-04-26 | Y |
| 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 | 2024-03-13 | 2024-04-26 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-03-13 | 2024-04-26 | 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 | 2024-03-13 | 2024-04-26 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-03-13 | 2024-04-26 | Y |
| Assess the resident when there is a significant change in condition | Health | 2024-03-13 | 2024-04-26 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2024-03-13 | 2024-04-26 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-03-13 | 2024-04-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-13 | 2024-04-26 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-03-13 | 2024-04-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-13 | 2024-04-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-13 | 2024-04-26 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-13 | 2024-04-26 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-03-13 | 2024-04-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-13 | 2024-04-26 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-13 | 2024-04-26 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-03-13 | 2024-04-26 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-03-13 | 2024-04-26 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-03-13 | 2024-04-26 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-03-13 | 2024-04-26 | 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 | 2024-03-13 | 2024-04-26 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-03-13 | 2024-04-26 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-13 | 2024-04-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-03-13 | 2024-04-26 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-03-13 | 2024-04-26 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-03-13 | 2024-04-26 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-03-13 | 2024-04-26 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-03-13 | 2024-04-26 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-04-10 | 2024-04-24 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-04-10 | 2024-04-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-04-10 | 2024-04-24 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-04-10 | 2024-04-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-04-10 | 2024-04-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-19 | 2022-11-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-19 | 2022-11-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-19 | 2022-11-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-15 | 2022-10-21 | Y |
| 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 | 2022-09-15 | 2022-10-21 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-15 | 2022-10-21 | Y |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2022-09-15 | 2022-10-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-15 | 2022-10-21 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-09-15 | 2022-10-21 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-09-15 | 2022-10-21 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-09-15 | 2022-10-21 | 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 | 2022-09-15 | 2022-10-21 | 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 | 2022-09-15 | 2022-10-21 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-15 | 2022-10-21 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-15 | 2022-10-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-25 | 2022-02-20 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-06-15 | 2021-07-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-06-15 | 2021-07-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-15 | 2021-07-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-06-15 | 2021-07-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-06-15 | 2021-07-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-15 | 2021-07-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-06-15 | 2021-07-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-06-15 | 2021-07-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-06-15 | 2021-07-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-06-15 | 2021-07-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-15 | 2021-07-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-15 | 2021-07-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-15 | 2021-05-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-15 | 2021-05-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-15 | 2021-05-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-04-15 | 2021-05-07 | 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 | 2021-04-15 | 2021-05-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-15 | 2021-05-07 | 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 | 2021-04-15 | 2021-05-07 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-04-15 | 2021-05-07 | N |
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