The facility failed to follow its own dementia care policies for the resident, identified in inspection records as R1. Garden Terrace's written policies required staff to identify and address dementia care needs, develop person-centered care plans, and create individualized interventions based on each resident's symptoms and rate of decline.
The policies also directed staff to review and revise care plans when they proved ineffective or when residents experienced changes in condition. Staff were required to modify the facility environment to accommodate resident care needs and achieve expected improvements or maintain stable decline rates.
None of this happened for R1.
Federal inspectors cited the facility for actual harm to the resident, determining that Garden Terrace's failure to address the escalating behaviors directly led to the hospitalization. The violation affected few residents but caused measurable harm to those involved.
The inspection report provided no details about the specific behaviors that escalated or the circumstances surrounding the hospital admission. Inspectors classified the deficiency as isolated, meaning it occurred in a limited area of the facility's operations rather than representing a widespread pattern.
Garden Terrace operates under policies that acknowledge the complex needs of dementia residents, including the requirement for individualized interventions tailored to each person's specific symptoms and progression rate. The facility's failure to implement these policies for R1 represents a breakdown in the dementia care program that the facility itself designed.
The complaint investigation concluded with inspectors determining that reasonable people would consider the facility's actions harmful to the resident's wellbeing and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Garden Terrace At Overland Park from 2025-12-30 including all violations, facility responses, and corrective action plans.